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Full text of "Anatomical atlas of obstetrics, with special reference to diagnosis and treatment"

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ANATOMICAL ATLAS 



OBSTETRICS 

WITH SPECIAL REFERENCE TO 

DIAGNOSIS AND TREATMENT 

BY 

DR. OSKAR SCHAEFFER 

Privatdocent in Obstetrics and Gynecology ij:i the University of Heidelberg 



AUTHORIZED TRANSLATION FROM THE SECOND REVISED 
GERMAN EDITION 



EDITED BY 



J. CLIFTON EDGAR, A.M., M.D. 

Professor of Obstetrics and Clinical Midwifery- in the Cornell University 

Medical College ; Attending Physician to the Mothers' and 

Babies' Hospital and the New York Maternity 



With 122 Figures on 56 Lithographic Plates, and 38 other Dlustrations 
PHILADELPHIA AND LONDON 

Vv^. B. SAUNDERS & COMPANY 
1 901 



Copyright. 1901, by W. B. SAUNDERS & COMPANY. 



Registered at Stationers' Hall, London, England. 



ELECTROTYPED BY PRESS OF 

WESTCOTT & THOMSON, PHILADA. W. B. SAUNDERS & COMPANY, 



EDITOR'S PREFACE. 



In the oriorinal, Dr. Sehaeffer's Atlases were most sue- 
cessfal, and we see no reason why they should not be 
equally popular in the English language. 

Volume I. many of us will remember as appearing in 
a much smaller book in the early nineties ; but this has 
now been much enlarged and brought up to date^ with 
111 pages of text and over 150 illustrations. 

Volume II. contains 314 pages and 160 valuable illus- 
trations. Here we are indebted to the author for a book 
which, although he terms it an ''Anatomical Atlas of 
Obstetric Diagnosis and Treatment/' still, by reason of 
its profusion of illustrations and diagrams, is in the main 
a text-book of great didactic value. 

The present volume treats particularly of the obstetric 
operations, and will be found of special value for the 
student as a book of reference to be used in conjunction 
with the larger treatises on obstetrics. 

As in Volume I., no alterations or additions have been 
made in the text, with the exception that the English 
equivalents have been added to all French weights and 
measures. 

J. CLIFTON EDGAR. 
50 East 34th Steeet, Xew Yoek, 
January, 1901. 



PREFACE TO THE SECOND EDITION. 

The appearance of the second edition of this work has 
been mnch delayed, because both the publisher and the 
author were well aware that this atlas, which was the 
first of the series to appear with colored illustrations, has 
been outstripped by the later issues, both as regards im- 
provements in the technique and the utilization of new 
clinical material. Meanwhile, the atlases have gained a 
place for themselves as practical manuals, -and for these 
reasons it became necessary to subject both the illustra- 
trations and the text to a complete revision. Most of 
the colored plates are new, and have been executed under 
my direction by the practised hand of Mr. Schmitson. 
The sources from which the new material was derived 
were the Heidelberger Frauenklinik and Poliklinik, the 
Pathological Institute, and the author's own practice. 
I am greatly indebted to the directors of those institu- 
tions, Drs. Arnold and Kehrer, and to their assistants, 
especially Professor Ernst. 

In regard to the material from the Miinchener Frauen- 
klinik which was included in the first edition, I refer to 
the preface to that edition, and renew the expression of 
my grateful appreciation of the ready kindness with which 
my former respected chief and master. Dr. von Winckel, 
not only placed that clinical material at my disposition, 
but assisted me, besides, with his inestimable suggestions, 



PREFACE TO THE SECOND EDITION. 

which are still found in the corresponding passages in 
the text and in the illustrations. 

In this revision 1 have been guided chietly by the 
demands of the practical, clinical side of obstetrics, and 
it is for this reason that all scientitic explanations and 
anatomic, histologic, and pathologic data are printed in a 
different type from that of the ordinary text. In this 
way I have fully preserved the peculiar character of an 
atlas accompanied by a complete abstract. 

Every chapter has been carefully revised and the liter- 
ature utilized. The advances made in the last few years 
have been considerable. Many questions have been 
brought nearer a final solution, many others have become 
more complicated, while new ones have made their ap- 
pearance. Hence it was often necessary either simply to 
cite all the reported findings, or in other cases to add to 
them a personal interpretation. Chapters of this kind 
are those on the youngest ova, on the chorionic epithe- 
lium and syncytium, on the epitheliomata of the chorion 
and deciduomata, the nature of the ^' lower uterine seg- 
ment " and the " contraction-ring," the treatment of 
ectopic gestation, hystereurysis and kolpeurysis, of reflex 
neuroses and anomalies of innervation, etc. In recogni- 
tion of the general tendency to consider the body as a 
complete entity, I have thought it advisable to add a 
chapter on the mutual influences which the individual 
organs exert on one another, both from a physiologic and 
a pathologic point of view, and I have therefore at- 
tempted to build up a practical system on the basis of 
my own experience and of the literature bearing on the 
subject. An effort has been made to discuss the symp- 
tomatology with the greatest fulness compatible with 



PREFACE TO THE SECOND EDITION. 

brevity, instead of dismissing the subject with a few 

stereotyped phrases which are of no use in the individual 

case. In like manner, the indications for treatment have 

been made more complete and at the same time more 

definite. 

Wherever it was possible, tables and schemes have been 

added so as to afford a general view of the subject under 

discussion. In conclusion, I must not omit to state that 

without the self-sacrificing cooperation of the publisher 

and the intelligence of Mr. A. Schmitson, such a large 

and complete collection of original drawings would not 

have been possible. I wish to express to these gentlemen 

my heartfelt thanks. 

OSKAR SCHAEFFEE. 



CONTENTS. 



PART I 

Physiology and Dietetics of Pregnancy, Labor, 
and the Puerperium. 

CHAPTER PAGE 

I. Physiology and Diagnosis of Pregnancy 11 

1. Development of the Ovum. Changes Observed in the 

Organs of Gestation during Pregnancy 15 

Ovuhition and Menstruation 17 

Fertilization and Propulsion of the Fertilized Ovum 

along the Oviduct 19 

Development of the Embryo and Fetal Membranes . 21 
Diagnosis and Anatomical Features of Each Month 

of Gestation 30 

2. Examination. Diagnosis of Pregnancy 35 

II. Anatomy, Development, and Examination of the 

Pelvis 49 

3. Diagnosis of the Normal Female Pelvis 49 

4. Shape and Inclination of the Adult Female Pelvis and 

its Development 56 

Variations in the Pelvic Inclination and their Practi- 
cal Value 60 

III. Normal Labor 62 

5. The Uterine Muscle and its Functions during Preg- 

nancy and Labor 62 

Labor-pains and their Effect on the Fetus 67 

6. The First or Dilatation Stage of Labor. Behavior of 

the Lower L^terine Segment and of the Cervix 
during this Period ... 75 

7. The Second Stage (Stage of Expulsion) and the Resist- 

ance offered by the Pelvic Planes and the Floor of 

the Pelvis 85 

3 



4 CONTENTS. 

CHAPTER PAGE 

IV. The Puerperium and the Treatment of the New- 
born Infant 96 

8. Physiology of the Puerperium 96 

9. Physiology and Feeding of the New-horn Infant . . .108 

10. Hygiene and Management of Pregnancy 123 

11. Symptomatology and Management of the Puerperium . 125 



PART II. 

Pathology and Treatment of Pregnancy, Labor, 
and the Puerperium. 

V. The Pathology of Pregnancy, including Abor- 
tion AND Premature Labor 134 

12. Anomalies which Lead to Abortion 134 

Diagnosis and Treatment of Abortion ...... 134 

Suhchorionic Hemorrhages 138 

Hydrorrhoea Uteri Gravidi 144 

Decidua Polyposa 145 

Hydatid Moles 145 

Polyhydramnion 147 

Inflammation of the Placenta 149 

13. Eclampsia Gravidarum 152 

14. The Eelations between Pregnancy and Diseases of 

other Organs 156 

15. Disturbances during Pregnancy due to Anomalies in 

the Shape and Position of the Genital Organs, 

especially the Uterus 168 

16. Tumors . . . .• 1'^'" 

17. Ectopic Gestation. Placenta Prapvia 191 

Ectopic Gestation • • • ^^^ 

Placenta Praevia • 199 



CONTENTS. 5 

CHAPTER PAGE 

VI. Deformities of the Pelvis and their Influence 

ON Pregnancy and Labor 204 

18. General Kemarks on the Diagnosis and Treatment 

of Deformed Pelves 204 

19. Anatomical and Obstetrical Peculiarities of De- 

formed Pelves 209 

Classification and Description of Deformed Pelves 212 

Generally Contracted Pelves 212 

Anteroposteriorly Contracted Pelves .... 215 

Collapsed Pelves"^ 222 

Funnel-shaped Pelves 22-3 

Obliquely Contracted Pelves 230 

Transversely Contracted Pelves 236 

Anomalies of the Pelvis due to Congenital or 

Earl}^ Acquired Defects 237 

Spondylolisthetic Pelves 239 

Assimilation-pelves with so-called ' ' Inter- 
calated ' ' Vertebra 241 

Anomalies of the Pelvis due to Bone-tumors 

and Exostoses the Eesult of Fractures . . . 242 

Generally Enlarged Pelves 243 

VII. Pathology of Labor 243 

20. Lacerations of the Genitalia during Labor .... 243 

21. Dystocia due to Anomalies in the Position and 

Form of the Genital Organs, including Tumors 254 

22. Dystocia due to Anomalies in the Ovum or Fetus . 262 

23. Anomalies in Labor-pains. Interdependence be- 

tween Labor and Diseases of other than the 

Sexual Organs 268 

General Remarks on Diagnosis and Indications 

for Operation in Dystocia 268 

Anomalies in the Labor-pains 270 

Interdependence between Labor and Diseases of 

other Organs 274 

VIII. General Remarks on Exploration for Purposes 

OF Diagnosis and Treatment 278 

24. Preparation of the Patient for Examination and 

Instrumental Delivery 278 

26. The Instrumentarium 281 



6 . CONTENTS. 

CHAPTER PAGE 

IX. Pathology of the Puerperium 283 

26. Puerperal Fever 283 

Treatment of Acute Pelveoperitonitis 292 

Treatment of General Septicemia and Sapremia 293 

27. Interdependence between the Puerperal Processes 

and other Diseases 296 

28. Diseases of the Mammary Glands during the Puer- 

perium 299 

Prescriptions Commonly Used in Obstetrical Practice . 802 

Index 307 



ILLUSTRATIONS. 



Plate. 


FiGVEE 


1 


1 




2 




3 


2 


4 




5 




6 




7 


3 


8 


4 


9 




10 




11 


5 


12 




13 


6 


U 




15 




16 


7 


17 


8 


18 


9 


19 


10 


20 


11 


23 


12 


24 


13 


25 


14 


26 


15 


27 


16 


28 


17 


29 




30 


18 


31 


19 


32 




33 



Ovary with Ampulla of Tube. 

Ovary with Corpus Luteum. 

Longitudinal Section of an Ovary. 

Transver.?e Section of Ovary from a Four-months" Fetus. 

Longitudinal Section thn jugh the Ovary of a Xew-born 
Infant. 

Cross-sections of an Oviduct. 

Cross-section through the Isthmus of a G-rarida. 

Embryo from an Abortion at the End of the Second 
) Month. 

' Chorion and Amniotic Sac with Ovum. 

Decidua Vera. 

Spurioas Fetal Hemains. 

Complete Ovum in the Second Month. 

Ovum of the Third Month. 

Transverse Section of the Vterus fntm a Six-months' 
Fetus. 
j Cells from Decidua. 

Chorionic Villus with Fetal Blood-vessels. 

Eare Vertical Position of the Gravid L'terus in the Third 
Month, following a Retroversion . 

Retroverted Uterus in the Second Month of Gestation. 
] Gravid Litems in the Fourth Month in a Primigravida. 

Gravid L'terus in the Sixth Month in a Primigravida. 

Lateral Placenta Pra-via. Sixth Month. 
j Fetus from the Sixth Month. 
I Complete Ovum from the Sixth Month. 

Fetal Surface of the Placental Organs of an Immature 
I Ovum in the Sixth Month. 

j Extrusion of the Placenta into the Cervical Canal. 
I Puerperal Uterus. 

! Vertical Sagittal Section of the Pelvis. 
! Coronal Section through the Pelvis, 
i Arteries of the Genital Organs. 

Position of the Xon-gravid L^terus. 
I Position of Fundus and Portio Vaginalis in Each 
! Month of Preornancv. 



ILLUSTRATIONS. 



Plate. 


FiGURK. 


20 


34) 




35 . 




36 


21 


37 




38 


22 


39 




40 




41 


23 


42 




43 




44 




45 


24 


46 




47 




48 


25 


49 




50 




51 


26 


52 




53 




54 


27 


55 




56 




57 


28 


58-60 V 
61-63 ] 


29 


30 


64 




65 




66 




67 


31 


68 




69 


32 


70 




71 




72 


33 


73, 74 


34 


75 




76 


35 


77 




78 




79 


36 


80 




81 


37 


82 




83 



External Examination. 

Vulva of a Primigravida. 

Colchicum-colored Fornix of the Vagina. 

Usual Position of Portio Vaginalis. 

The Head has Entered the True Pelvis. 

Antero vertical Position of Portio Vaginalis. 

Measurement of Transverse Diameter of Outlet. 

Accurate Measurement of True Conjugate with the 

Pelvimeter. 
Measurement of External Conjugate. 
Accurate Measurement of Transverse Diameter of 

Inlet. 
Palpation of Spinec of the Ischium. 
Sagittal Section through a Petal Pelvis. 
Sagittal Section through Fully Dilated Birth-canal. 
IS'ormal Female Pelvis. 
Generally Equally Contracted Pelvis. 
Greatly Contracted Funnel-shaped Pelvis. 
Female Fetal Pelvis. 
Sagittal Section through a Fetal Pelvis. 
The Same in the Adult. 

Sagittal Section of Normal Adult Female Pelvis. 
Measurement of Transverse Diameter of Inlet. 
Effect of Pressure of the Thighs and Traction of Ilio- 

sacral Ligaments on Shape of the Pelvis. 

Pelvic Angles in Various Positions. 

Superficial Layers of Uterine Muscle. 

Deep Layers of Uterine Muscle. 

Arrangement of Muscle-fibers. 

Decidua Vera. 

Nerve-supply of Female Genitalia. 

Muscles of the Perineum. 

The Pelvic Inlet. 

The " Principal Plane " of Veit. 

Plane of Pelvic Expansion. 

Skull of a Child at Term. 

Transverse Section of Pelvis at Level of Internal Os. 

Rupture of the Cervix and Vaginal Fornix. 

Venous Plexuses of the Pregnant Uterus. 

Lymphatics of the Female Genitalia. 

Secreting Cells of Mammary Gland. 

Mammary Gland of a Primigravida in the Seventh 

Month. 
Necrotic Decidua. 
Lochia Rubra. 
Lochia Serosa. 



ILLUSTRATIONS. 



Plate, 


Figure. 




84 




85 




86 




87 


38 


88 


39 


89 


40 


90 


41 


91 




92 


42 


93 




94 


43 


95 


44 


96 


45 


97 




98 




99 


46 


100 




101 


47 


102 




103 


48 


104 




105 


49 


106 


50 


107 




108 


51 


109 




110 


52 


111 


53 


112 




113 


54 


114 




115 


55 


116 




117 


56 


118 




119 




120 


57 


121 




122 




123 


58 


124 




125 




126 


59 


127 




128 




129 


60 


130 




131 



Lochia Alba. 

Colostrum -cells. 

Milk. 

Section through Wall of Puerperal Uterus. 

Mummified Fetus with Ketained Abortive Ovum. 

Hydatid Mole. 

Decidual Endometritis. 

Decidual Hemorrhage. 

Subamniotic "Fibrin." with Cysts and Extravasation. 

Syphilitic Inflammatory Villi. 

Syphilitic Umbilical Cord. 

Placental Infarct. 

Placental Infarct in Eclampsia. 

Uterus Bicornis Septus. 

Uterus Introrsum Arcuatus. 

Pendulous Abdomen of Third Degree. 

Twisting of Umbilical Cord and Oligohydramnion of a 

Dead Twin. 
Placental Infarcts. 
Retroflexion of a Gravid Uterus. 
Partial Retroflexion of a Gravid Uterus. 
Hernia Labialis Uteri Gravidi Bicornis. 
Prolapse of Retroflexed Gravid Uterus. 
Fibromyoma of Lower L'terine Segment. 
First Face Presentation. 
Subserous L^terine Myoma. 
Total Prolapse of Retroflexed Gravid Uterus. 
Transverse Rupture of Uterus. 

Gestation in Rudimentary Horn of a Uterus Unicornis. 
Tubal Pregnancy. 
Ruptured Tubal Gestation-sac. 

Perforation of a Tubal Sac into Bladder and Rectum. 
Ovarian Pregnancy. 
Abdominal Pregnancy. 
Interstitial Extra-uterine Pregnancy. 
Flat ISTon-rachitic Pelvis. 
Flat Rachitic Pelvis. 

Generally Contracted Flat Rachitic Pelvis. 
Flat Rachitic Pelvis of High Degree. 
Compressed Rachitic Pseudo-osteomalacic Pelvis. 
Compressed Osteomalacic Pelvis. 
Zone of Ossification in a ISTormal Epiphysis. 
Zone of Ossification in a Rachitic Epiphysis. 
Section through an Osteomalacic Bone. 
Conical Abdomen. 
Pendulous Abdomen, First Degree. 
Pendulous Abdomen, Second Degree. 
Cephalic Presentation. 
Curve of the Sacrum. 



10 



ILLUSTRATIONS. 



Plate. 


FlOUBE. 




132 


61 


133 




133a 


62 


134 




135 




136 


63 


137 




138 




139 




140 


64 


141 




142 




143 




144 


65 


145 




146 




147 


66 


148 




149 




150 


67 


151 


68 


152 \ 
153/ 


69 


70 


154 




155 




156 


71 


157 




158 


72 


159 



Shape of the Skull. 

Brow Presentation. 

Hydrocephalus. 

Infantile Funnel-shaped Pelvis. 

Rachitic-kyphotic Funnel-shaped Pelvis. 

Kyphotic Funnel-shaped Pelvis. 

Asymmetrical Assimilation Pelvis. 

Double Promontory in Sagittal Section. 

Obliquely Contracted Pelvis. 

Superior Strait of a Eight Obliquely Contracted Pelvis. 

Right Obliquely Contracted Pelvis. 

Left Obliquely Contracted Pelvis. 

Spondylolisthetic Pelvis. 

Robert's Transversely Contracted Pelvis. 

Flat Anteroposteriorly Contracted Pelvis. 

Transversely Contracted Oval Pelvis. 

Split Pelvis. 

Acanthopelys. 

Exoftosis. 

Cystic Enchondroma. 

Oblique Presentation : " Conduplicato Corpore. " 

Complete Rupture of the Uterus. 

"Face" Presentation of an Anencephalus. 
Presentation of Dicephalus Dibrachius. 
Presentation of Thoracopagus. 

Hydrocephalus Presenting with Head in Partial Flex- 
ion. 
Distention of Bladder and Ureters. 
Puerperal Diphtheritic Endometritis and Colpitis. 



PART 1. 

Physiology and Dietetics of Preg- 
nancy, Labor, and the Puerperium. 



CHAPTER I. 
PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Various Reasons for Determining the Exist- 
ence of Pregnancy. — The physician may be called 
upon to determine the existence or non-existence of preg- 
nancy for various reasons. His opinion is anxiously 
souo^ht by those who fear the possible consequences of 
illicit indulgence, and even in lawful wedlock many con- 
tingencies arise whicli make it desirable or even indispen- 
sable to determine the existence of pregnancy and the date 
of its termination. The information is asked for as eagerly 
by the elderly couple, with an ardent desire for an heir 
after a long and sterile marriage, as by the anxious parents 
blessed with a large family but ill supplied with the neces- 
saries of life, or by a husband solicitous for the health of 
his wife, whose constitution may be weakened by tubercu- 
losis or other disease. The date of impregnation is often 
a matter of great importance, as, for instance, when a 
widow is called upon to prove the legitimacy of her child 
born afrer her husband's death ; or for the purpose of 
calculating the probable time of delivery, so that it shall 
not conflict with a long sea-voyage or a change of resi- 
dence ; or, finally, in the case of a late arrival, to enable 

11 



12 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

the mother to make the necessary provisions for concealing 
the fact from the older children. 

The early recognition of pregnancy may have an im- 
portant hearing on the decision of a divorce suit, Avhether 
the wife be or be not accused of adultery, and I need not 
in this place enter into any further discussion of the im- 
portance of such a finding from a medicolegal point of 
view. 

In his own interest the physician should never allow 
himself to forget the possibility of pregnancy in any 
female patient who may consult him for a "gynecological'^ 
complaint of the lower abdomen, or even in one who 
presents marked pathological changes in the sexual organs. 
The statements of such a patient should always be received 
with skepticism, as she frequently has a reason for wishing 
to deceive the physician, and, if possible, induce him to 
undertake some intra-uterine or other local treatment in 
the hope that he may bring on an abortion. On the other 
hand, there are women who deceive themselves, either in 
imagining themselves pregnant when they are not, or 
vice versa, according to their temperament and desires. 
Before the diagnosis is finally settled and a line of treat- 
ment decided upon, the question of pregnancy must be 
determined by a careful objective examination. 

Even an ordinary intra-uterine pregnancy may be very 
difficult to recognize during the first months, and in the 
case of a tubal or ovarian pregnancy the diagnosis is only 
too often quite impossible, although if it were made early 
it might, by determining surgical interference, prove the 
means of saving the patient's life. 

It will be seen from the foregoing that there is an early 
period, embracing the first two or even three months, 
during which the existence of pregnancy cannot be recog- 
nized with certainty, and a late period, from the end of 
the third month to term, when a positive diagnosis is in 
ordinary cases possible. 

The Signs of Pregnancy. — The diagnosis, to be 
positive, must rest on the recognition of some part of the 



RELATIVE VALVE OE THE SIGNS OE PREGNANCY. 13 

ovum, the fetal envelo})es, or the fetal Ixxly ; or on the 
detection of the cliaracteristic fetal symptoms, especially 
tlie "fetal heart-sounds/' about 140 short, rapid beats per 
minute, resembling the muffled ticking of a watch, or the 
soft "funic souffle/' heard synchronously with the fetal 
heart-beats. 

A knowledge of the anatomical conditions is essential 
in making the diagnosis. It is necessary to know : 

(1) The size and shape of the fetus in the different 
months of pregnancy ; 

(2) The position of ovum and fetus in utero ; 

(3) The changes in the uterus itself accompanying 
the development of the ovum^ and the manner in which 
these changes manifest themselves in the different 
months ; 

(4) The changes observable in other portions of the 
genital tract ; 

(5) The influence of pregnancy on the other organs of 
the body. 

Relative Value of the Signs of Pregnancy. — 
The findings under (1), which emanate from the child^ are 
called infallible signs of pregnancy ; those under (3) and 
(4), emanating from the maternal organs, are called prob- 
able signs, while those under (5), which might be observed 
in the male as well as in the female subject, are classed as 
unreliable signs. The existence of pregnancy may be 
considered more or less probable according to the number 
of signs observed belonging to the last two groups. They 
acquire importance only when it is impossible to elicit any 
of the " infallible '^ signs, as, for instance, in the first 
month of gestation, or after the death of the fetus, which 
had escaped recognition by palpation on account of its 
small size or marked malformation. They must be utilized 
whenever no fetal murmurs can be heard — as in cases of 
polyhydramnios, in myxomatous degeneration of the ovum 
(so-called vesicular mole), in the case of a co-existing 
tumor, or in ectopic gestation. 

The detection of many of these "probable" and "un- 



14 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 1. Ovary with Ampulla of Tube.— The fimbriated extremity of 
the tube, loosely held iu place by the ovariopelvic fold of peritoneum, is 
attached to the broad ligament, although less firmly than the isthmus. 
The gaping morsus diahoU is seen with a stalked hydatid hanging from 
it; a small cyst is also seen on the fimbria ovarica. These structures are 
present in four-fifths of all individuals and represent, when situated in 
the anterior layer of the broad ligament, the atrophic remains of the 
transverse tubules of the lower part of the Wolffian body ; or they may 
be pedunculated fimbriae covered with epithelium. The surface of the 
ovary is grayish-red and presents on its upper margin a structure of 
similar appearance, which is a Graafian follicle, while several deeper lying 
follicles can be made out by their bluish color shining through the tunica 
albuginea. The furrows represent the scars of follicles which have burst 
and been converted into corpora fibrosa or candicantia. The upper border 
of the ovary is covered by peritoneum, or rather embedded in a fold of 
the membrane; the boundary, known as Farre's line, can be seen in the 
figure (original water-color, natural size). 

Fig. 2. Ovary with Corpus Luteum (original water-color, natural size) 
laid open; underneath, a cyst laid open, with myoma of the uterus. 
The follicle, which may attain the size of a pea, is ruptured by the inter- 
nal pressure at the time of the menstrual congestion, the ovum escaping 
into the peritoneal cavity. The follicle then becomes filled with clotted 
blood and large cellular elements containing fat and a yellow pigment — 
the lutein-cells, derived from the follicular epithelium, or, according to 
others, from the granular cells of the internal tunic {membrana granulosa), 
and is then called a corpus luteum. It is often traversed by radiating 
connective-tissue septa, and the center is occupied by coagulated blood, 
which may persist a long time and contain hematoidin crystals. 

Fig. 3. Longitudinal Section of an Ovary (original water-color, natural 
size), showing the cortcr., in which Graafian follicles in various stages of 
development are embedded, and the medulla., richly supplied with blood- 
vessels. The outermost laj^er is formed by the fibrous tunica albuginea, 
covered with cuboidal epithelial cells. 



reliable" sig-ns of pregnancy must be learned by constant 
practice, and the search for them should never be neglected. 
If the physician has had an opportunity of examining the 
patient before she became ])regnant the diagnosis is, of 
course, much easier, as the size, position, and consistency 
of the unimpregnated uterus are known. During the 
first month the picture of a normally progressing preg- 
nancy is obtained by comparing the changes observed at 
two successive examinations made at an interval of three 
to four weeks. 



jO 

H 








V 



j&t^ 



^ 




& 



DF^VELOPMEXT OF THE OVUM. 15 

These changes affect the shape, size, blood- supply, con- 
sistency, color, and specific functions of the organs. 

§1. DEVELOPMENT OF THE OVUM. CHANGES OBSERVED 
IN THE ORGANS OF GESTATION DURING PREGNANCY. 

The ovary, in which the ova are formed, is an almond- 
shaped organ, measuring from IJ to 2 in. (3 to 5 cm.) in 
length, partially covered by a fold of peritoneum, the 
mesovarium, and embedded in the posterior layer of the 
broad ligament. It is attached to the uterus by means 
of the ovarian Ugamentj and to the Fallopian tube or 
oviduct by means of the fimbriae, which are covered with 
ciliated epithelium and form part of the tubo -ovarian 
ligament. The pull of this ligament gives to the ampulla, 
which is freely movable, a downward curve, so as to bring 
its opening, the morsus diaboli or ostium abdominale, nearer 
the ovary. The free portion of the tubo-ovarian ligament, 
together with the curved tubal portion of the broad liga- 
ment, yv'iih which it is continuous, forms a tent-like cover- 
ing for the ovary — the ovarian sac (bursa ovarii). 

The ovary is usually found below the pelvic inlet, in a 
sagittal plane midway between the superior spine of the 
ilium and the symphysis, corresponding in height and 
direction to the iliopectineal line at its center (AValdeyer), 
and embedded in the posterior portion of the obturator 
fossa. It is surrounded by the ureter, the internal iliac, 
and uterine arteries, and lies within the fossa ovarii, which 
occupies the posterior ])art of the lateral wall of the pelvis 
near the margin of the sacrum. At this point it is 
attached by the suspensory ligament of the ovary, the 
inffimJibuIopelvic band, which transmits the ovarian vessels. 
The vermiform appendix usually descends as far as this 
region, being sometimes connected with the oviduct by a 
narrow fold of peritoneum, the plica ovarico-enterica. 

The surface of the ovary (Fio:s. 4 and 5) is covered with a single 
layer of cuboidal epithelial cells, derived from the same source as 
the large endothelial cells of the peritoneal covering, although 
there is a distinct boundary-line between them. In the third 



16 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 4. Transverse Section of Ovary from a Four-months' Fetus 

(microscopical : original drawing from author's specimen). — Explanation 
of numbers as in Fig. .5. 

Fig. 5. Longitudinal Section through the Ovary of a New-horn Infant, 
showing a Mature Follicle (niicioscopical ; original drawing from au- 
thor's specimen) : 1, sharply outlined endothelial cells at hilum, merging 
into 2, cuboidal germinal epithelium ; .3, an ovum embedded in the follic- 
ular epithelium, which is derived from germinal epithelium by prolifera- 
tion of Pfliiger's cell-cords, showing zona pellacida, yolk, germinal vesicle, 
and germinal spot ; 4, follicle lined with a single layer of epithelium and 
containing one ovum ; 7, one with two ova; 5, capillaries; 6, primitive 
ova; 8, fully matured Graafian follicle, showing the fibrous theca follicuU, 
membrana gramdosa, discus proligerus, ovum, and liquor foUicnli, which is 
seen pushing the surface of the ovary upward ; 9, immature follicle with 
ovum. The other spaces, lined with a single layer of cuboidal cells, 
represent follicles in which the ovum did not happen to be included in 
the section. 10, blood-vessels, lymphatics, and nerves entering the hilum 
from the broad ligament in company with the intraligamentary connec- 
tive tissue. 

Fig. 6. Cross-sections of an Oviduct (microscopical ; original draw- 
ing from author's specimen) : a, near the ostium internum, which is rich in 
muscle-fibers, the mucosa has few papillae ; b, through the isthmus, four 
papillfe in mucosa ; c, near the ampulla, poor in muscle-fibers, but rich 
in papillfe; 1, peritoneal endothelium; 2, subserous connective tissue 
with blood-vessels (4) ; 3, muscularis. essentially circular in shape ; 5, 
ciliated epithelium. 

Fig. 7. Cross-section through the Isthmus of a Gravida (microscopical ; 
original drawing from author's specimen): 1, endothelium; 2, subserous 
connective tissue containing numerous blood-vessels; .3, muscular coat 
with markedly dilated vessels, as at 4. for instance, where the vessel 
appears in oblique section; 5, columnar epithelium which, with the 
stroma, forms the characteristic papillae appearing in the fifth month. 

month of fetal life this germinal epithelium, as it is called, begins 
to proliferate, and dips down into the loose connective-tissue 
stroma of the cortex in the form of Pfliiger's cell- cords, after 
traversing the thickened outer layer of stroma known as the tunica 
alhuginea. The ova develop within the true ovarian stroma. In 
their primitive stage they appear among the cuboidal epithelial 
cells as large cellular elements with a nucleus and nucleolus, later 
as globular masses, consisting of germinal epithelium and several 
primitive ova, pushing their way into the stroma. From these 
masses are formed the primary follicles in which each ovule has 
separated from the mass and become surrounded by small epithe- 
lial cells derived from the walls of the follicle. The latter finally 
develops into the mature Graafian follicle. By proliferation of 



Tab. 2. 








Fig. 5. 




Fig. 6. 



Fig 7. 

Lith.Anst F. Ruduwld. Mimchjen. 



DKVFAJJPMENT OF THE OVUM. 17 

the follicular epithelium the zona r/ranulosa, and later, the discus 
proligerus, are formed, within which, situated near one pole, the 
mature ovum is formed. The ovum now consists of the radially 
striated zona pellucida, yolk, germinal vesicle, and germinal spot, 
entangled in the meshes of chromatin-fibers. Inside the zona 
gramdosa the discus proligerus is surrounded by the liquor folliculi, 
which separates it from the wall of the follicle. The follicle is 
covered by a layer of greater density, the fheca foUieuli or tunica 
propria et fibrosa. Xerves have been found in the discus proligerus. 
Xo D-anglion-cells have as vet been demonstrated in the ovarv 
(v. Herff ). 

The center of the ovary is occupied by the medulla, the stroma 
of w^hich is richly supplied with, blood-vessels and nerves derived 
from the intraligamentary connective tissue. 

OVULATION AND MENSTRUATION. 

The ovaries are at all times filled with ova in various 
stages of development. An overdistended Graafian folli- 
cle bursts and an ovum is discharged. Two or more 
follicles may rupture at the same time and give rise to a 
twin or multiple pregnancy, or the fecundation of more 
than one ovum. The overdistention and rupture of a 
Graafian follicle are caused by an increase in the blood- 
pressure within the ovary, which occurs at intervals of 
three to four weeks, hence, under normal conditions, the 
escape of the ovum into the peritoneal cavity recurs at 
regular periods coincident Avith the time of greatest blood- 
pressure. The pressure begins to rise about the middle 
of the intermenstrual period, hence, even at this time, any 
accidental congestion of the generative organs may bring 
about the distention and rupture of a follicle. It has been 
proven by postmortem studies on pregnant women who 
had died of heart disease, that this periodical determina- 
tion to the generative organs continues during pregnancy ; 
the rupture of a follicle during this period is, therefore, 
possible, and explains the occurrence of superfecundation 
or impregnation of an ovum after the development of an 
embryo has begun, and even of superfetation (after the 
sixth week).^ 

^ This is denied bvmost American authorities ; see Piersol, in American 
Text-BooJ: of Obstetrics, p. 144.— Trans. 

2 



18 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

The escape of the ovum from tlie ovary is termed ovula- 
tion; while the regularly recurring determination of blood 
to the generative organs has received the name of menstru- 
ation, because it occurs usually at intervals of about four 
weeks. Both processes are evidently under the control 
of a central regulating apparatus ; for, although the local 
hemorrhage from the genitalia is the most conspicuous 
pathological feature, the entire organism not only during 
the three or four days of the catamenial period but also 
during the entire space of four weeks is subjected to 
fluctuations in blood-pressure, metabolism, and innervation, 
culminating in the establishment of the menstrual flow. 
Thus the determination to the generative organs is a grad- 
ual process, starting about the middle of the intermenstrual 
period and culminating in a local hemorrhage from the 
congested mucous membrane of the uterus. If the escap- 
ing ovum is not fertilized, the congestion of the mucous 
membrane and the active regenerative processes in its 
epithelial and glandular structures subside, the parts re- 
turn to their former condition, and the epithelium of the 
mucous membrane separates here and there in shreds over 
the site of submucous ecchymoses. This disintegrating 
process usually occupies about two weeks. 

Metal^olic activity is at its height shortly before the 
menstrual period, sinks as soon as the catamenial flow is 
established, and continues at its lowest during the three 
or four days of the menstrual period. The changes in 
the other generative organs are undoubtedly dominated 
by the ovarian process ; without the latter there can be no 
menstruation. Artificial congestion of the ovaries by 
injection is followed by hyperemia of the uterine raucous 
membrane (Strassmann). 

The ovaries can be transplanted in the same animal to other por- 
tions of the peritoneal cavity without suffering any impairment of 
function ; they continue to share in the congestion of the uterus, 
and may even inaugurate a normal pregnancy (Knauer). 

On the other hand, if both ovaries are removed the uterus 
undergoes atrophy and the blood-vessels degenerate, the epithelial 
and glandular portions of the mucous membrane being first 



DEVELOPMENT OF THE OVUM. 19 

affected. The ovaries also undergo retrograde metamorphosis 
after extirpation of the uterus. 

In a sense the ruptured follicles also share in the men- 
strual hemorrhage. If impregnation has occurred the 
hemorrhage within the follicle is more marked and the 
ovaries become enlarged and succulent. After the escape 
of the ovum the cells lining the inner surface of the fol- 
licle (follicular epithelium or the granular cells of the 
internal tunic) undergo proliferation and fatty change, 
there is an invasion of round cells, and a yellow body, 
the corpus luteum {verum), is formed. 

The wall of the follicle separates in folds, hematoidin-crystals 
are deposited, the entire mass becomes organized, and the prolif- 
eration of connective tissue forms a scar — corpus fibrosum s. ccmdi- 
dans. The corpora lutea appear to be concerned with the main- 
tenance of normal circulation and blood-pressure within the 
ovary. 

Tubal menstruation may occur in certain pathological 
conditions. 



FERTILIZATION AND PROPULSION OF THE FERTIL- 
IZED OVUM ALONG THE OVIDUCT. 

When the ovum reaches the peritoneal cavity it is 
carried toward the pavilion of the oviduct partly by the 
ciliary movement of the fimbriae and partly by the current 
of the thin layer of serous fluid which normally covers 
the entire peritoneum. This. current is produced by a 
sucking action emanating from the ampulla, the mucous 
membrane of which is free from glands and consists of a 
substratum of longitudinal bundles of connective tissue 
containing numerous round cells, surmounted by a layer 
of short ciliated columnar cells, which generate a ciliary 
current toward the narrow ostium internum. The same 
current effects the removal of a non-impregnated ovum. 
If fecundation has occurred, the muscular fibers of the 
tube also assist in the propulsion of the ovum. It is 
possible for an ovum to find its way into the opposite 



20 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. S. Embryo from an Abortion at the End of the Second Month 
(original water-color, natural size). — The decidua shows numerous ex- 
travasations ; the chorion, which is held up and expanded, is detached in 
places. Through the opening a view of the interior of the amniotic sac 
is obtained, showing the umbilical cord and several subamniotic hema- 
tomata. The ovum must have been ruptured during labor and the 
embryo expelled with the amniotic fluid, unless, as happens frequently 
in early abortions, the embryo died first and was absorbed. 



tube either by external or intraperitoneal or, in rare cases, 
by internal uterine transmigration. 

It follows from the foregoing description that the oviduct may 
be divided into two segments: the uterine idhmus with a very 
narrow lumen, lined with smooth mucous membrane, but possess- 
ing a robust muscular layer, and the ampulla, of a much larger 
caliber and provided with a thickly corrugated mucous mem- 
brane. From the folds of this membrane are formed the morsm 
dlaboli and the fimbriae which surround the ostium abdominale. 
The fimbriae begin to appear in the third or fourth month of fetal 
life. At this time the extremities of the tubes are partly united 
with the surface of the ovary, forming the so-called ovarian tubes, 
which occasionally persist and may give rise to a tubo-ovarian 
gestation. 

In transverse sections the lumen of the tube presents a stellate 
outline (Figs. 6 and 7). At the uterine extremity there are three 
papillary projections; in the intermediate portion four primary 
and several secondary papillae, the former appearing as early as 
the fifth month and containing numerous unstriated muscle-fibers, 
while the entire lumen of the ampulla is filled with richly 
branched processes. There are no actual mucous glands, but in 
health the surface is constantly bathed with a small amount of 
mucus secreted by the cells of the mucous membrane. 

The inusciilaris mucosw is composed of a robust median zone of 
circular, and a lesser external zone of longitudinal, fibers. The 
tube is covered with peritoneum for three-fourths of its circum- 
ference, the remaining fourth corresponding to the hilum. The 
latter is formed by intraligaraentary connective tissue which con- 
tains tlie blood-vessels and surrounds the entire tube under the 
peritoneal covering. 

Impregnation may occur at any point in the oviduct. 
By virtue of their ciliary movement the spermatic fila- 
ments are able to reach the fundus uteri within a few 
hours, and they retain their vitality a week or more after 
coitus, in the uterus, in the tubes, or even on the peri- 



Tab. 3. 




Fig 8. 



LUh. Ami E ReUhhold. Mimchen 



DEVELOPMENT OF THE OVUM. 21 

toneum. The chances of fertilization are greatly enhanced 
by the circumstance that the ovum and spermatic filament 
travel the same path, and by the enormous number of 
the latter discharged at one ejaculation. Impregnation 
probably takes place most frequently in the ampulla. 

DEVELOPMENT OF THE EMBRYO AND FETAL MEM= 

BRANES. 

Several spermatic filaments may enter the ovum ; the nucleus 
of one of these blends with the female pronucleus, which remains 
after the extrusion of the polar bodies. The extrusion occurs 
whether the ovum is fecundated or not. A small mass of pro- 
toplasm enters the ovum along with the male pronucleus and the 
zona pellucida is formed, enclosing the ovum in a denser envelope. 
The process of segmentation now begins and results in the forma- 
tion of the blastodei^mic vesicle, presenting a field of greater den- 
sity, which marks the first indication of the embryonal area. By 
the sinking in of this embryonal area the blastula becomes con- 
stricted and divides into two portions, connected by the ductus 
omphalomesaraicus. The blastula now consists of two layers: the 
ectoderm and the entoderm. From the former are derived the 
skin, the nervous system, and the organs of special sense; from 
the latter, the epithelial structures (glands) of the intestines. 
Between these two layers and springing from both is the mesoderm, 
which later develops into the vascular system, connective tissues, 
muscles, and sexual organs. The ectoderm is the first to appea-r. 

After the formation of the primitive groove the medul- 
lary folds begin to rise on either side of the medullary 
furrow. Even before thev unite and close in the medul- 
lary canal, the embryo becomes completely enveloped in 
a sac filled with fluid — the amnion — which grows back- 
Avard from the ununited body walls, surrounds the em- 
bryo, and unites behind, in a line parallel with the dorsal 
folds. At first closely adherent to the ectoderm, the 
amnion gradually separates as the amniotic fluid is formed. 
This separation is effected before the fourteenth day, when 
the embrvo is from i to li in. (2 to 3 cm.) long;. 

The zona pellucida, the striations of which are due to 
the presence of intercellular processes running from the 
ovum to the cells of the follicular epithelium, now be- 
comes converted into a membrane provided with numer- 



22 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 9. Clioiioii and Amniotic Sac with Ovum, between the Second 
and Third Month (uiiginal water-color).— The chorion ifrondosum), which 
at this period still surrounds the entire ovum, is laid open, showing the 
interior of the aniuiotie sac and the head of the embryo. 

Fig. 10. Decidua Vera (original water-color, see Fig. 8).— A portion 
of it is still intact and covered with blood-clots. Compare these true 
fetal membranes with : 

Fig. 11, which represents spurious fetal remains, consisting of fibrin 
and blood-clots. 

Fig. 12. Complete Ovum in the Second Month (original drawing from 
a specimen obtained at the Miinich Gynecological Clinic). — The "win- 
dow" in the decidua vera reproduces the triangular shape of the uterus; 
/. M., OS uteri ; o.t., openings of the oviducts. We see the decidua reflexa 
{D.c), the chorion {Ch), and within the amuion {Am) the embryo (brain - 
vesicles, visceral arches, four extremities, prominence of cardiac and 
hepatic regions, and the caudal extremity with the long coccygeal 
point). 

Fig. 13. Ovum of the Third Month (original drawing).— We see de- 
cidua reflexa {D.c), the chorion (Ch) laid open, and the amnion {Am) 
closed. The fetus h suspended by the umbilical cord [Xah.). which is 
seen through the membranes. Tlie head is large in comparison with the 
body. 



ous villi, consisting principally of ectoderniic cell-cords 
which bind it firmly to the amnion. It is fnrtlier attached 
to the embryo by means of an abdominal stalk, the future 
umbilical cord. Through this structure the embryo 
obtains its nutriment by means of vessels which at first 
derive their material from the vitelline circulation {arterice 
et vencE omphalomesaraicce), as they form a network 
around the vitelline sac. The remains of this structure 
are sometimes found at birth as a minute, flat, yellowish 
mass not far from the insertion of the cord into the pla- 
centa, along one of the folds of the amnion (B. S. Schultze). 
About the middle of the first month the aUantoic sac 
makes its appearance at the caudal pole of the embryo, 
growing from the region of the hind-gut and urachus. 
It contains the umbilical vessels which dip down into the 
branching ectodermic blood-islands of the chorion. The 
umbilical cord breaks up into the countless chorionic villi 
of the placenta. The latter push their way into the uter- 
ine mucous membrane, which is denuded of its epithelial 





>^.S#'''' 



ik> K-M^ 



M:>-. 




^ 






LMi 



WS^ 




DEVELOPMENT OF THE OVUM. 23 

coverino; or soon becomes so by the ingrowth of the villi, 
and into the capillarie.^, whose endothelial lining also dis- 
appears ; the capillaries between the villi become greatly 
enlarged and filled w^ith blood, constituting the intervillous 
spaces. Here, by a process of osmosis and an interchange 
of gases, the nutrition and respiration of the embryo is 
effected ; it is the so-called allantoic circulation which 
persists till birth, is subject to the pressure of the uterine 
vessels in the chorionic villi, and is maintained by the 
action of the fetal heart. The villi are covered by a 
sino^le laver of ectodermic cells, the forerunners of the 
protoplasmic nucleated syncytial cells by which the nutri- 
ment and maternal albumin are conveyed to the embryo. 

At first the chorion surrounds the embryo in its entire 
circumference (see Figs. 9 and 12). Until the end of the 
first month the chorion measures |- in. (2 cm.) in diame- 
ter ; the length of the embryo is less than |- in. (1 cm.), 
about J to -J- in. (7 to 8 mm.) ; the cephalic flexure is 
fully developed. In the brain it is possible to distinguish 
the beginnings of the cerebral hemispheres from the mid- 
brain ; the limb-buds are present ; the liver begins to 
appear as a distinct prominence, which later can be plainly 
seen from the outside. 

The chorion is, therefore, a fetal envelope of embryonal 
origin. It is in turn enclosed in a product of the uterine 
mucous membrane — the decidua reflexa (or circumflexa) — 
called deciduous because cast off and becoming useless at 
birth. The decidua vera (Figs. 8, 12, 67, a and h) is 
simply the hypertrophied and vascular uterine mucous 
membrane of pregnancy, which extends as far as the 
internal os, or, in rare cases, a few centimeters into the 
cervical canal. Another fold of mucous membrane, iden- 
tical in structure, is thrown around the free convex border 
of the chorion which ])rojects into the cavity of the uterus, 
opposite its point of attachment to the uterine mucous 
membrane. This maternal envelope has received the name 
of decidua reflexa. 

Judging from comparative investigations on animals, it 



24 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 14. Transverse Section of the Uterus from a Six-months' Fetus 
(microscopical ; original drawing from authors specimen) at the level of 
the internal os : 1, single layer of cylindrical ciliated epithelium, secreting 
mucus, with primitive glandular depressions; the S-shaped lumen is 
characteristic of the cervical portion of the uterus, and depends on the 
plicx palmate, or dendritic folds of the cervical canal {arbor vitie) ; 2, con- 
nective-tissue stroma of the mucous membrane, containing many round 
cells, especially under the epithelium, and traversed by blood-vessels; 3, 
bundles of muscular tissue, the tibers are for the most part obliquely 
circular with arteries radiating among them : 4, subserous connective tissue 
through which the arterial trunks make their way from 6, the intraliga- 
laentary connective tissue containing the main j^ranches of the uterine 
artery; scattered here and there are single bundles of muscle-fibers in 
transverse section; 5, peritoneal endothelium. 

Fig. 15. Cells from Decidua. 

Fig. 16. Chorionic Villus with Fetal Blood-vessels (microscopical ; 
original drawing from teased preparation). — Embryonal mucous connec- 
tive tissue covered with a protoplasmic baud containing nucleus (as de- 
scribed in the text) and fetal blood-vessels. (Xote. — According to the 
latest discoveries the cuboidal epithelium with the cross-markings is 
found only during the first two weeks.) 



appears most probable that the ovum '^ eats its way," so 
to speak, into the decidua by means of the chorionic villi, 
or, as V. Herff expresses it, ^'builds a nest for itself" in 
the hypertrophied decidna. This type is seen in Sanger's 
ovum from a tubal pregnancy of two and a half weeks, 
examined by Fiith. 

The mucous membrane of the uterus, as is to be expected 
from the complex nature of its functions, is a much more 
highly specialized organ than any other mucous membrane 
in the body. 

In the primitive form (Fig. 14), as seen in the new-born, the 
lumen of the uterine body presents in transverse section a curved 
slit with its convexity looking backward, lined with a single layer 
of columnar epithelium and sending hut few processes into the 
submucous stroma— the forerunners of the complicated mucous 
glands which develop later, especially in the cervical canal. The 
vascular system in the submucosa is well developed even at this 
early date, the ramification of the capillaries being quite pro- 
nounced. The arterial trunks ])ass almost vertically through the 
circular and oblique fibers of the muscularis, hence in adults the 
arteries are completely closed by violent or tetanic contractions, 



:o 



OS 

Eh 










^ 





i 

I n 









-^ .r 









DEVELOPMENT OF THE OVUM. 25 

and even moderate contractions may compress them to a consider- 
able extent. Muscular contractions may be vigorous enough to 
cut off' the sup}»ly of blood, and, therefore, of oxygen to the fetus; 
while, on the other hand, they may be utilized as a means of 
stopping an uncontrollable hemorrhage. 

Anatomically the uterus is naturally divided into two 
parts : the hodij^ which in the virgin state is flattened and 
about the size and shape of a pear ; and the cylindrical 
cervix, narrower than the body, the conical extremity of 
which projects into the vagina, and thus justifies the name 
portio vaginalis. 

The cervical canal communicates with the vagina by 
means of the external os. Its chief function is the secretion 
of alkaline mucus, which has marked beictericided quali- 
ties and serves to lubricate the vagina. It is possible that 
the mucous plug which occludes the cervix may in some 
way facilitate impregnation. The intermediate portion 
of the cervical canal is somewhat dilated and contains the 
plicce palmatce {arbor vitce), which in the fetal uterus form 
obliquely placed valves similar to those observed in the 
sheep. 

The columnar epithelial cells secrete mucus and are accordingly 
very well developed. The club-shaped cells of the cervix are the 
best developed of any in the body ; the lower protoplasmic portion 
containing the nucleus elaborates the mucus, which is stored for use 
in the upper portion of the cell. The cells are provided with cilia 
which generate a current directed from the fundus to the cervical 
canal (Hofmeier, Mandl). The shape of the cells is strongly 
influenced by external conditions. Between the cells are preformed 
intercellular spaces traversed by delicate fibrils of protoplasm. 

The cervical canal communicates with the cavity of the 
uterus by means of the narrow and sensitive interned os, 
which is occasionally closed l)y valves directed toward the 
fundus, the remains of infantile structures. Under normal 
conditions the ovum is attached above the internal os, 
hence the uterine cavity represents the specialized segment 
destined for the reception and development of the ovum. The 
mucous membrane of the corpus uteri only becomes con- 
verted into the decidua, and the menstrual hemorrhage is 



26 PHYSIOLOGY AND DIAGNOSIS; OF PREGNANCY. 

Fig. 17. Rare Vertical Position of the Gravid Uterus in the Third 
Month, following a Retroversion (original drawing). — Sagittal section 
through the median line of the pelvis. The ovum does not extend below 
the body of the uterus; the cervical canal and both the internal and the 
external os are closed. The external os is directed downward and back- 
ward, and descends lower than is the case in the virgin uterus and in a 
normally placed uterus. The gravid body of the uterus has lost its flat- 
tened, pyriform shape, is more balloon-shaped, with the greatest enlarge- 
ment in the sagittal plane. The envelope, consisting of decidua and 
chorion, is still fairly uniform, but is beginning to show a local thicken- 
ing at the future site of the placenta, where the umbilical cord is in- 
serted. The uterus is still within the true pelvis; between it and the 
abdominal wall there is room for intestines and omentum ; above the 
internal sphincter the rectum, or rather the sigmoid flexure, is seen 
greatly distended ; the bladder is contracted. 



limited to this structure. In this portion of the generative 
canal the cohimnar cells are accordingly shorter and more 
regular in form. 

The uterus requires a large blood-supply, which is de- 
rived from two sets of vessels wholly independent of each 
other, whose relations are well shown in Fig. 31. 

Distribution and Relations of the Arteries of the Uterus 
(and of the Ureters). (Fig. 31): Ur, ureters; i2, kidneys; Ut, 
uterus in ante version, displaced forward to permit a view of 
Douglas' pouch; the rectum and peritoneum have been removed; 
T, tubes ; Ov, ovaries ; Co, cervix ; Lg. r., round ligament, running 
from the insertions of the tubes into the fundus along the bladder 
to the inner portion of the groin (dissected out from the broad 
ligament). Within the connective tissue of the triangular-shaped 
broad ligaments we see on either side the large uterine arteries, 
coming from the region of the hypogastric arteries and the ])elvic 
walls and passing down by the side of the uterus to the cervix, 
giving off branches to the vagina and to the vulva. A small 
branch goes directly to the cervix, or the latter may be supplied 
by the uterine artery itself on its return toward the fundus after 
passing below the internal os. The branches form a tortuous net- 
work which is quite characteristic and persists after impregnation 
has occurred, thus enabling the vessels to accommodate themselves 
to the changes in volume incident to pregnancy. They run first 
in the subperitoneal tissue (see Fig, 14), thence they radiate into 
the mucosa after forming an intermediate zone of ramifications in 
the muscular coat for the supply of the latter. 

Along the upper border of the uterus the uterine arteries form 
a free anastomosis with the ovarian arteries, resulting in a subperi- 



Tal). 7 




Fig. 17. 



Ansf [\ Reicfijwld. Miiiichen. 



DEVELOPMENT OF THE OVUM. 27 

toneal vascular network. These arteries are branches of the 
aorta; entering the broad ligament from above they pass along 
the infuudibulopelvic bands from the ampulla to the i)elvic wall 
and supply principally the ovaries, tubes, and fundus uteri. The 
above-mentioned anastomosis ascends along the tubes to meet the 
ovarian artery and is usually very well developed. 

During gestation the blood-supply to all the generative 
oro^ans becomes much more abundant, even the lio;amentarv 

O J CD ^ 

structures in the pelvis suffer a serous infiltration. The 
effect of the labor-pains is to check the flow of arterial 
blood through the muscular wall of the body of the uterus 
— the lower uterine segment and cervix are not affected — 
and to overfill tlie veins. It follows, therefore, that the 
respiratory process in the placenta is periodically em- 
barrassed for a fraction of a minute during labor. 

The decidua cells are large polygonal or oval elements, 
sometimes spindle-shaped from pressure, and containing 
several nuclei when cell-division is very active (Fig. 15). 
They are formed by proliferation of the stroma-cells and, 
with the enormously dilated capillaries which branch out 
into veritable sinuses, reach almost to the epithelium, and 
constitute the decidual tissue. The interstitial connective 
tissue is poorly developed. Similar cells have also been 
observed on the serous surface of the broad ligament in 
ordinary intra-uterine pregnancies. 

The chorionic villi penetrate into the interspaces between 
the decidual cells, and these in turn send out processes 
which project into the intervillous spaces. The villi sub- 
serve two purposes : 1, the larger and more robust, con- 
taining connective tissue and only a single arterial trunk, 
form attachments to the maternal tissue ; 2, the smaller, or 
nutrient villi, with branched processes containing capillaries 
which grow into the capillary spaces of the maternal 
tissue, serve to nourish the fetus. There is no direct flow 
of blood from mother to fetus. The intervening wall is 
made up of the endothelial cells of the maternal and fetal 
capillaries and the nucleated protoplasmic covering of the 
chorionic villi (syncytium). The question of the origin 
of the latter, whether embrvonal or maternal, has not as 



28 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 18. Retroverted Uterus in the Second Month of Gestation (after 
a frozen section by Braune). — As the cervix is forced upward aud forward 
by the increasing retroflexion of the body, there is danger of incarcera- 
tion under the curve of the sacrum as pregnancy progresses. The neck 
of the bladder may be pressed upon and distorted to such a degree as to 
cause dangerous ischuria. 



yet been definitely settled; it is probably derived from 
the embryo (trophoblast). In very young ova the syn- 
cytium is represented by a single layer of cuboidal cells 
derived from the ectoderm, but later it forms a continuous 
band of protoplasm with nuclei embedded in it here and 
there, covering the vascular embryonal mucous coimective 
tissue of mesodermic origin. The various embryonal and 
maternal tissues also combine to form conglomerate masses 
of cells. 

This close relation between the chorion and the decidua, 
as here described, does not, however, persist along the 
entire periphery. In the course of the first three months 
the villi in contact with the decidua reflexa and the mem- 
brane itself cease to grow and even undergo marked 
atrophy, while at the place where the chorion comes into 
direct relation with the decidua vera its connection becomes 
more and more intimate and voluminous, and finally cul- 
minates in the formation of the placenta serotina. A part 
of the decidua reflexa sometimes retains its placental 
character, and thus gives rise to the formation of the 
placenta circnmvallata. The fourth month witnesses the 
completion of the true placenta, a fiat, cushion-like disk 
C^cake"), closely adherent to the anterior or posterior 
wall of the uterus (rarely to both, by passing over one 
margin or over the fundus), from which the true fetal 
envelopes, now reduced to thin membranes, proceed to 
enclose the fetus and the umbilical cord w^ithin the amni- 
otic sac. 

The nutrition and oxygenation of the fetus is effected by 
means of an interchange of gases and the passage, by 
osmosis, of fluids and watery solutions and even of formed 
elements. [The passage of oxygen was proven by Zweifel's 



Tab. 8. 




Fig. 18. 



LUh. Anst /.' ReuhtwLd. SUutxhen 



DEVELOPMENT OF THE OVTM. 29 

demonstrating the oxyhemoglobin-band in the spectrum 
of the blood in the umbilical vein. Tlie passage of car- 
bonic oxide, chloroform, ferrocyanide of potassium, iodide 
of potassium, salicylic acid, iinely divided cinnabar, meth- 
ylene blue, toxins, typhoid-fever and tubercle bacilli from 
the maternal blood into the fetus and the amniotic fluid, 
across the l)oundary l)etween chorion and decidua, and also 
in the contrary direction from fetus to mother, is well 
established.] Albumin in considerable quantities is un- 
doubtedly conveyed to the fetus, probably by some com- 
plicated process, through the agency of the chorionic 
epithelium. As has been mentioned, the interchange is 
effected by the chorionic villi ; the fetal blood is conveyed 
to them by the two umbilical arteries, and leaves them, 
after having been purified, in the single nmbi/ical vein. 
The latter passes from the umbilicus to the liver, through 
the ductus Arantii (venosus), which later becomes oblit- 
erated, and the inferior vena cava, which carries very little 
blood up to the ])oint where it is joined by the ductus 
venosus, to the right auricle. As the two venae cavse are 
joined bv the umbilical vein before thev enter the rio-ht 
auricle, the fetal heart is supplied only with mixed blood, 
but metabolism is so slio^ht, owino; to the inactivitv of 
most of the organs (lungs, digestive apparatus, and glands), 
that the nutrition is not impaired. The active portions 
are chiefly the voluntary muscles, the heart, and the kidneys, 
and this functional activitv, tog^ether Avith the chemical 
processes associated with tissue-formation, suflice to give 
the fetus a temperature of its own, although relatively low. 
The fetal temperature is 1° F. (J° C.) higher than the 
maternal. During intra-uterine life the two auricles com- 
municate, the valve over the foramen ovale being still 
open, as the pulmonary circulation has not yet been estab- 
lished. Hence the blood in the rio^-ht auricle and in the 
pulmonary artery is carried directly to the aorta through 
the ductus Botalli (arteriosus), which later becomes oblit- 
erated. The iliac arteries o^ive off* the umbilical arteries, 
which run in the umbilical cord and convey part of the 



30 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

blood out of the body into the placenta, ichere the transfer 
of excrementitious j^rodads of metaboUiim into the maternal 
blood takes place. 

The amniotic fluid (liquor amnii) consists princi])ally 
of an exudation from the maternal blood-vessels in the 
chorion and umbilical cord, the amnion representing a 
true serous membrane ; a small portion of the fluid is 
contributed by the regular functional activity of the fetal 
skin and kidneys. The fluid contains from 0.05 to 0.5 
per cent, of albumin and is swallowed by the fetus (lanugo 
hairs are found in the meconium) ; its function is not, 
however, to nourish the fetus, but to protect it from ex- 
ternal injury and to allow it free movement. 

DIAGNOSIS AND ANATOMICAL FEATURES OF EACH 
MONTH OF GESTATION. 

We have so far studied the development of the embryo 
and of its envelopes during the first month of gestation. 
During this period the anatomical alterations in the 
maternal organs, especially the uterus, are so insignificant 
that the diagnosis cannot be made with any degree of 
probability except in individuals previously known to the 
observer; indeed, until the end of the fourth month, 
when the parts of the fetal body can be felt, there can be 
no such thing as absolute certainty. Until that time the 
degree of probability will de])end on the skill and ex- 
perience of the examiner, tlie anatomical characteristics 
of the subject (thin abdominal walls, absence of meteorism, 
tumors, or complications in the form of inflammatory 
processes or cramps), the number of probable signs of 
pregnancy observable, and the peculiarities of the indi- 
vidual. 

!^nd of the First Month. — Uterine enlaigement 
cannot be made out ; it amounts to no more tlian the en- 
largement observed at every menstrual period. Tlie con- 
sistency also is the same as at the menstrual period. The 
retroversion and sinking which take place in the begin- 
ning of the second month are not constant phenomena. 



DEVELOPMENT OF THE OVUM. 31 

Sometimes the body of tlie uterus is felt with remarkable 
distiuctness close to tlie anterior vaginal vault and shows 
a marked increase in its sagittal diameter. 

'i1ie ovum weighs 38 gr. (2.5 gm.) ; the embryo is | in. 
(0.8 cm.) in length. 

End of the Second Month. — The uterus is the size 
of an apple, balloon-shaped instead of flattened from 
before backward; the internal os is circular (in primi- 
gravidse) ; the vagina and portio vaginalis are livid (Fig. 
38) ; the internal os begins to soften. 

The ovum is the size of a hen's egg. The embrvo has 
assumed a distinctly human shape, the face (by closure 
of visceral clefts), head, and extremities being fully 
formed. When this change takes place the product of 
conception is about f in. (1.5 cm.) in length, and from 
this time on is termed a " fetus." By the end of the 
second month its length is 1 in. (2.5 cm.) and the head is 
as large as the trunk. The formation of the placenta 
serotina begins about this time, the decidua reflexa grad- 
ually undergoing atrophy. If the ovum is prematurely 
expelled at this period the process is still called an 
"abortion." 

Serum can be expressed from the mammary glands. 
They are enlarged, turgid, and heavier than before preg- 
nancy ; the swollen acini can be felt as thickened cord- 
like wheals radiating from the nipple. The pressure on 
the stomach gives rise to reflex nervous symptoms in the 
form of dyspepsia, and especially " morning sickness." 
In very neurotic individuals these symptoms become 
greatly exaggerated, often to the extent of uncontrollable 
attacks of vomiting — hyperemesis gravidarum. 

:End of the Third Month. — The uterus is the size 
of a child's head ; the fundus reaches to the upper border 
of the symphysis (see Fig. 17); the portio vaginalis is 
tilted backward. As the uterine body develops much 
more rapidly than the cervix, it appears like a round ball 
on a pedicle. The marked softening of the loiver uterine 
segment (Hegar's sign) above the sacro-uterine ligaments 



32 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 19. Gravid Uterus in the Fourtli Month in a Primigravida. — The 

uterus is flabby and bulges iu various places. The iutestiues have been 
pushed away from the abdominal wall and the fundus projects above 
the symphj'sis. A portion of omentum is seen interposed between the 
womb and the abdominal wall. The fetus possesses considerable mobil- 
ity until after the middle of gestation, hence the position of the head 
in the fundus ; in other words, the breech i)resentation is nothing un- 
usual. At this time the true placenta is fully developed. The fetal 
membranes cover the internal os. The anterior and posterior walls of 
Douglas' pouch appear as two narrow clefts along the bladder and rectum 
respectively ; posteriorly the subserous lamina is seen extending deeply 
into the rectovaginal septum. The vagina is narrow and the rugse are 
well marked ; the perineum is intact ; the external os is closed — all 
signs of a first pregnancy. 

Fig. 20. Gravid Uterus in the Sixth Month in a Primigravida.— The 
fundus extends almost to the umbilicus. Note the usual attitude of the 
fetus (about one-third natural size), huddled together, with head and 
extremities flexed. 

is best felt by inserting the forefinger into the rectum and 
the thumb into the vagina against the portio vaginalis, 
while the womb is pressed down from above with the 
other hand. 

The ovum is the size of a goose-egg (Fig. 13). 

T\\Q fetus measures 3| in. (9 cm.) and weighs 308 gr. 
(20 gm.) ; the head is half as large as the. trunk ; the 
umbilical cord is longer than the fetus and begins to show 
twisting. 

:^nd of the Fourth Month.— The uterus is as large 
as a man's head and palpable above the symphysis; the 
true pelvis is entirely filled. Parts of the fetal body can 
be recognized by their increased resistance (first reliable 
sign). It is possible to hear the uterine bruit synchronous 
with tlie maternal pulse, a faint breath-like sound ema- 
nating from the arteries. 

The fetus measures 4 to 6|- in. (10 to 17 cm.) and 
weighs 1 to 4^ oz. (30 to 1 20 gm.). The sex can be recog- 
nized by the external genitalia. If born "prematurely'' 
(not "viable") the child makes respiratory movements 
(see Fig. 19). 

Bnd of the Fifth Month. — The fundus is midway 



ai) t 




Fig. 19. 



Tab. 10. 




Fig. 20. 



i.iih.: 



DEVELOPMENT OF THE OVUM. 33 

bctireeii the si/)nphysis and the uvthi/tcu.'^, its transverse diam- 
eter coinciding usually with the rii2;lit oblique diameter of 
the pelvis (from the ri(jht sacro-iliac junction to the opposite 
iliopectineal eminence). In multigravidse the external 
OS is sufficiently relaxed to admit the examining finger. 
Strise and pigmentation appear on the abdomen (along the 
liiiea alba) and breast, forming in the latter situation the 
secondary areola. 

The fetus measures 8 to 10 in. (20 to 25 cm.) and 
weighs 5 to 12J oz. (140 to 350 gm.). Fetal heart-sounds 
begin to be audible from the eighteenth to the thirtieth 
weekj and about the same time fetal 7novements can be both 
felt and heard ; later they can also be seen. 

Bnd of the Sixth Month. — The fundus extends 
to within 1^ to 11 in. (3 to 4 cm.) of the umbilicus ; the 
latter begins to become shallow from below. The uterus 
gradually assumes a more oval shape and thus determines 
the longitudinal position of the fetus. Softening of the 
cervix extends to a point above its middle. The portio 
vaginalis is on a level with the spine of the ischium, but 
appears shorter on account of the fold formed by the 
hypertrophied vagina. The mother inclines the upper 
part of the body slightly backward in walking. 

The fetus measures 10^ to 13^ in. (26 to 34 cm.) and 
weighs 15 to 33^ oz. (430 to 950 gm.) ; whimpers if born 
prematurely. Ujj to this month we speak of " immature 
birth " — partus immcdurus (see Fig. 20). 

:End of the Seventh Month. — The fundus extends 
IJ to 1^ in. (3 to 4 cm.) above the umbilicus; the latter 
is flattened. 

The fetus measures 14^ to 15 in. (36 to 38 cm.) and 
weighs 29 to 40^ oz. (820 to 1150 gm.) ; emits a wail if 
prematurely born ; the skin is wrinkled and thickly cov- 
ered with hair; the pupillary membrane begins to dis- 
appear. As a rule, a presenting part of the child (one 
of the poles of the longitudinal axis) can be felt per 
vaginam ; the joarfe of the fetal body are easily distin- 
guished. 



34 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 23. Lateral Placenta Prsevia, Sixth Month (belongiug to PI. 12; 
original water-color).— We see the interlacing of the larger villi which 
serve for attachment with the smaller, delicate, branching villi and the 
decidua on the maternal surface. The lower, bleeding portion corre- 
sponds to the part detached during birth ; below are the fetal envelopes. 

Fig. 24. Fetus from the Sixth Month (two-thirds life size; belonging 
to Plate 11 ; original water-color), delivered in incomplete foot presenta- 
tion. — The skin is wrinkled and red ; the nails do not reach quite to the 
tips of the fingers ; the cord is edematous and gelatinous. 

Fig. 25. Complete Ovum from the Sixth Month (original drawing] : 
P/, placenta serotina; Ch, chorion; Am, amnion, laid open. The cord 
passes over the shoulder and back (one-third life size). The fetus shows 
the characteristic attitude as described above (see Fig. 20). 

l^nd of the Bighth Month. — The fundus is mid- 
icay between the umbilicus and the epigastric fossa. The 
secretion of the mammary glands makes its appearance. 
To preserve her equilibrium the woman is forced to lean 
over backward. 

The fetus measures 16 to 17 in. (40 to 43 cm.) and 
weighs 46 to 57^ oz. (1300 to 1600 gm.) ; can be kept 
alive with great care. The arms are very fat and red ; 
the skin is wrinkled (see Fig. 24). 

Bnd of the Ninth Month. — The fundus is in the 
epigastric fossa, about 1} in. (3 cm.) below the ensiform 
p7^oeess. Toward the end of the month the internal os is 
open in multiparce, the external os, in primiparce. Greatest 
abdominal distention. 

The fetus measures 18^ to 19^ in. (46 to 48 cm.) and 
weighs 71 to 95 oz. (2000 to 2700 gm.). The head is 
less movable and has engaged in the pelvic inlet. 

The ovum is still confined to the uterine cavity proper ; 
the internal os now begins to expand, the parts having 
become softer and more distensible. 

Tenth Month. — The fundus ocGU\nes the same posi- 
tion as in the eighth month and then usually sinks lower. 
Before the ovum begins to free itself from its attachments 
the fundus falls to a point midway between the ensiform 
process and the umbilicus. Its position varies, however, 
with the strength of the uterine contractions ; the cause 



Tab. 11, 




Fig. 23. 



LLlh . Anst F. Reichhold, Miinrhdi 




/' 



^r 



\ 



^, 



Tab. 13. 




Fig. 25. 



EXA3ri2^A TION. 35 

of this is found in the descent of the presenting part into 
the true pelvis, in primiparae as far as the pelvic expansion. 
The child measures 19^ to 201- in. (48 to 52 cm.) and 
weighs 6^ to 8 lb. (3000 to 3600 gm.) on the average; 
(imniottGjiaid, 53 oz. (1500 gm.) ; the placenta weighs one- 
fifth as much as the child (14 to 21 to 35 oz. - 400 to 600 to 
1000 gm.) ; the unibilical cord measures 16 in. (50 cm.) — 
the extremes are in deficiency of the abdominal wall, 
and 64 in. (200 cm.). The uterine wall becomes progres- 
sively thinner (segmentum chartaceum), so that the sutwes 
and fontanels of the fetal head can he plainly felt through 
the anterior va2:inal vault. 

To determine whether a child is mature w^e first ascer- 
tain the length of the body, then the weight, and the 
horizontal (fronto-occipital) circumference of the head, 
which is, on the average, 13|- in. (34 cm.). There are, in 
addition, other signs of maturity : the epidermis is thicker 
and the color of the skin pinkish instead of the deep-red 
fetal color; the hair on the head is abundant and several 
centimeters long, while on the body the lanugo hairs have 
mostly disappeared, except on the back, the shoulders, and 
the nape of the neck ; the bones of the skull are fairly 
firm, tlie fontanels and sutures small ; the nails project 
beyond the tips of the fingers ; the descent of the testicles 
into the scrotum is usually complete ; in girls the nymph?e 
are covered by the labia majora, so that there is no gaping 
of the vulva. 

The following thumb-rule for calculating the length of the fetus 
from the month of pregnancy is well known : from the first to the 
fifth month the length in centimeters is found by squaring the 
month (thus 1. 4, 9, 16, 25 cm.); after that date, bv multiplying 
the month by 5 (thus, 5 X 6 = 30, then 35, 40, 45, 50 cm.). 



I 2. EXAMINATION. DIAGNOSIS OF PREGNANCY. 

By inspection, palpation, auscidtafion, and mensuration 
we ascertain : 

1. The existence or non-existence of pregnancy; 2. 



36 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 26.— Fetal Surface of the Placenta of an Immature Ovum in the 
Sixth Month (original water-color). — The fetal membranes are stripped 
back over the margin in consequence of the placenta having been de- 
livered in advance of the fetus. The fetal surface is recognized by the in- 
vesting amniotic sac, under which are seen the large branching vessels 
of the placenta going to and coming from the umbilical cord. Tlie 
branches of the umbilical vein are distinguished from the two arteries 
by their lighter color. In this specimen the umbilical cord is gelatinous 
and edematous; it contained four vessels, one of the arteries forming 
several loops. 

Fig. 27. Extrusion of the Placenta into the Cervical Canal (marginal 
placenta prxvia ; original water-color made at the autopsy of a woman 
Avho died in the sixth month of pregnancy). — The umbilical cord pro- 
jected from the os, and the ruptured membranes, with the margin of the 
placenta, were visible within the cervical canal, which is held open and 
expanded from side to side to afford a view of the uterine cavity. The 
greater part of the placenta, embracing the central portion and upper 
margin, still adheres to the uterine wall. The spot from which the pro- 
truding portion of the placenta detached itself is recognized by the 
clotted blood from the ruptured uteroplacental vessels. Numerous ovula 
Nahothi were observed about the margin of the external os. 

Fig. 28. Puerperal Uterus from a woman who died of typhoid fever 
two days after a miscarriage in the fifth month (original water-color). — 
The placental site is easily recognized, as is the boundary between the 
uterine and cervical mucous membrane, which is clearly indicated by 
the difference in color. Analogous differences are fouiid in the uterine 
wall ; the upper limit of a " lower uterine segment," belonging to the 
body of the uterus and therefore beginning above the internal os. is 
indicated by a sudden thickening of the muscularis. Two ovula Nahothi 
are seen at the internal os. besides numerous similar bodies at the ex- 
ternal OS. The outer portion of the mucous membrane of the portio 
vaginalis, as well as that of the vagina, are anemic. The latter is the 
seat of several icteroid cysts, especially near the vaginal vault. 

the month of pregnancy ; 3, the position of the fetus ; 
4, the life or death of the fetus. 

By inspection we determine the increase in tlie circum- 
ference of the abdomen, its sliape — whether conical, pen- 
dulous, globular, or bul2:ing in the two hypochondriac or 
hypogastric regions and flattened about the umbilicus — 
the presence of recent or old sfrice gravidarum ; pig- 
mentation of the median line of the abdomen and its 
extent ; the condition of the breasts — their tension, the 
presence of nodes and cords (determined by palpation) — 



Tab. 14. 




Fig. 26. 



LW. 



fieidilwld. Munchen 




w^ 



Fig. 27 




Tab. 16. 




Fig. 28.' 



EXAMINATION. 37 

the color of the areola. The patient is asked whether she 
has felt dragging and stabbing sensations and increased 
weight, and whether milk or a serons fluid can be ex- 
pressed from the breasts. 

In Figs. 34-36 four different positions of the hands in 
palpation are shown. By the jiist method (Fig. 34) the 
height of the fundus is determined ; the second (Fig, 34) 
enables the physician to palpate the back and extremities 
of the child, and to detect fetal movements if any are 
made [back to the left, head below = first vertex presenta- 
tion (L. O. A.) ; back to the right, second vertex presen- 
tation (R. O. A.]. The third and fourth methods are 
employed to locate the fetal head, whether it is felt as a 
hard, round mass, more or less movable above the pelvic 
inlet, or has already entered the pelvis, remembering the 
differences between a primipara and multipara in this 
respect. They also enable the examiner to form an ap- 
proximate estimate of the child's length, which is often 
very desirable, as it affords a clue to the child's age and 
to the size of the head in proportion to a contracted pelvis. 
It is found by experience that the distance from the head 
to the coccyx, w^hen the fetus is bent on itself, is equal to 
half the length of the body. This measurement is most 
easily made in oblique positions of the fetus. 

The results of palpation are confirmed by auscultation. 
Vie can hear the soft, blowing uterine bruit, synchronous 
with the maternal pulse and the fetal heart-sounds (120-150 
double beats) ; sometimes also the short, blowing funic 
souffle, synchronous with the fetal heart. If the fetal 
heart-sounds are heard the fetus is unquestionably living. 
In the first vertex presentation the fetal heart-sounds are 
heard most distinctly at a point midway between the 
umbilicus and the left anterior superior spine of the ilium, 
emanating, when the fetal back is rotated forward by the 
labor-pains, not from the back, but from the breast of the 
fetus. Fetal movements are often heard as early as the 
fourth month — quick, sharp noises like the ticking of a 
watch — either spontaneously or when the uterus is irri- 



38 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 29. Vertical Sagittal Section of the Pelvis through the Ligament, 
Not Including the Uterus (modified from Freund) : 1, horizontal ramus 
of the OS pubis ; 11, ascending ramus of the ischium ; 2, vesico-uterine peri- 
toneal excavation ; 3, bladder ; 4, tube in transverse section ; 5, ureter ; 
6, peritoneal fold of recto-uterine excavation (7) ; 9, attachment of the 
uterosacral muscular bands running to the sacrum; 10, rectum. The 
vagina and portio vaginalis are seen through the opening. 

Fig. 30. Coronal Section through the Pelvis, showing the Muscles, 
Fasciae, and Ligamentous Bands in the Neighborhood of the Genital 
Tract : 1, peritoneum ; 2, superior or deep ; 5, inferior or superficial layer 
of tlie triangular ligament [2, pelvis; 5, perineum proper]; 4, levator 
ani muscle, embracing the vagina ; 3, connective tissue above, and 6, below 
the fascise (2 and 5) covering the levator ani muscle; 7, obturator fascia; 
8, constrictor cunni (continuation of the sphincter ani from the coccyx 
to the symphysis) ; 9, obturator internus. 

For explanation of Fig. 31, Arteries of the Genital Organs, see ^ 1, 
p. 26. 

tated bv rubbing or kneading. Later the sounds are more 
dull. 

In rare instances singultus and trembling of the lower 
jaw, as in a crying child, have been heard (Meyer, 
Zurich). 

INTERNAL EXAMINATION. 

A vaginal examination during pregnancy subserves a 
variety of purposes : In the first place, it is the only 
means of arriving at a diagnosis during the first half of 
gestation. It reveals the character of the pelvic cavity and 
of the soft parts, the presence of any obstacle which might 
interfere with the subsequent course and termination of 
pregnancy ; and finally, at the end of gestation, the signs 
of approaching labor. After labor has begun, however, 
internal examination is dangerous and should be made 
only for very urgent reasons. The mucous membrane is 
soft and easily injured by the examining finger, and the 
puerperal uterus, from its deep situation ^^ithin the abdom- 
inal cavity and enormous capacity compared to the caliber 
of the canal which drains it, is extremely liable to infec- 
tion, being filled with necrotic material, thrombi, and 
blood, especially if the body-temperature continues high. 



Tab. 17. 




Fig. 30. 



liih.Anst E ReichJwld-.Miuichen. 



Tab. 18. 




Fig. 31. 



EXAMTyATTO^\ 39 

The clanger of infection is therefore greater than in any 
other kind of wound, particularly after the membranes 
have ruptured. The busy practitioner, especially the 
country doctor who is rarely able to get any one to take 
his place, should remember in such cases that absolute 
surgical cleanliness cannot possibly be achieved ^vithin 
twenty-fours hours after contamination by attendance on 
a puerperal-fever patient, by the dressing of an infected 
wound, or by exposure to the germs of scarlet fever, 
diphtheria, etc. In any case a full bath and complete 
change of dress are imperative. The examiner's hands 
and the woman's vulva must be disinfected with the 
utmost care, the former even for the examination of a 
pregnant woman. 

In a critical case the question to be answered is : Do the 
best interests of mother and child urgently demand a 
vaginal examination ? 

Seamless rubber gloves which do not in the least inter- 
fere with the sense of touch are very useful. 

The best mefJiod of disinfecting the skin of the hands, 
vulva, and abdomen consists in vigorous rubbing with a 
brush and plenty of hot water and soap or soda-solution, 
so as to remove all the fat from the pores. Sand may 
also be used, with proper care, to make the rubbing more 
effective. Any folds in the skin are to be carefully 
smoothed out and rubbed clean. Tie examiner must first 
clean his nails^ which should be cl )sely trimmed, with a 
nail-file and a soft cloth. 

The parts are then scrubbed with alcohol, if any is at 
hand, and lastly with some antiseptic fluid, whereupon 
the examiner, without drying his hands or anointing them 
with a doubtful so-called '" carbolated oil" preparation, 
inserts his forefinger into the vagina, while with the other 
hand he separates the lips of the vulva, which has pre- 
viously been carefully cleansed. Before proceeding with 
the vaginal examination the bladder and rectum must be 
emptied, as otherwise accurate results are impossible. 

In this connection may be mentioned the peculiar livid 



40 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 32. Position of tlie Non-gravid. Uterus, wlieii the bladder and 
rectum are moderately di.stended. Peritoneum and subdivisions of the 
cervix indicated by red lines (original drawing). — The uterus lies 
normally in a position of antevei'siou and slight anteflexion, in close rela- 
tion with the bladder, to which the cervix is firmly attached in the 
median line by means of bands of connective tissue. The uterus, there- 
fore, follows the movements of the bladder. The body of the uterus is 
freely movable, being limited only by the intestines, and is covered with 
peritoneum (red line), an anterior fold extending into the vesico-uterine 
excavation as far as the internal os, while a posterior fold, lining the 
recto-uterine space or Douglas' pouch, extends lower and sends out tw^o 
processes : the first, formed by a fold of peritoneum at the level of the 
posterior fornix, contains the uterosacral muscular bands which run to the 
sacrum ; while the second is on a level with the external os. The cervix 
is divided into three portions : 1, the s^qyravaginal portion, extending from 
the internal os to the posterior fornix ; 2, the intermediate portion, from 
that point to a line drawn through the anterior fornix ; 3, the portio 
vaginalis proper. 

The uterine cavity and vagina together represent a curve with its 
concavity looking toward the symphysis. The vagina is a muscular 
tube with thin walls and a larger lumen than that of the uterus, the 
"portio vaginalis" of which projects into it and forms the deep po.sfeWor 
and short anterior fornix. In cross-section the lumen of the vagina pre- 
sents the shape of a capital H. The vagina is held as in a sling by the 
levatores ani muscles and their continuations, the constrictores cunni (see 
Figs. 9, 29, 30, 69). The vaginal passage is closed at the introitus by the 
hymen or its remains, the caruncnlae myrtiformes, behind which th.Q fossa 
navieularis is situated. Externally the canal is closed by the labia and by 
the perineum, with the frenulum periyiei (fourchette) between the labia. 

It is of practical moment to remember that above the perineum the 
rectovaginal septum becomes much narrower, corresponding to the point 
where the ampulla of the rectum comes into close relation with the 
vagina. 

Fig. 33. Position of Fundus and Portio Vaginalis in Each Month of 
Pregnancy (after B. S. SchultzeV— The numbers with periods after them 
indicate the various positions of the fundus and portio vaginalis and the 
degree of abdominal distention. The other numbers refer to the ana- 
tomical designations common to all the figures in the author's atlases 
(see Index). 



coloring of the vulva, resembling the color of wine-yeast 
or the blossoin of the colchicum plant (see Fig. 37), which 
may be observed at any stage of pregnancy, often after 
the failure of the first menstrual flow. During^ the later 



05 



OS 




^^^^^^^s^^ 






C9 
CO 

6i 




CO 



EXAMINATION. 41 

months edema and phlehectasla of the external pudenda 
are often observed. 

Tlie examiner's attention should be directed to the 
following points : the state of the perineum and pelvic 
floor, whether yielding or rigid, or, in multiparse, showing 
the scars of previous tears ; whether the introitus is over- 
HOisiiire to the examining finger ; whether there is any 
tendency to vaginismus; the state of the vagina, whether 
soft and smooth or rough (in inflammatory conditions and 
in many multiparse) ; the amount of secretion on the 
vaginal walls, and whether they are relaxed and thrown 
into folds, or rigid and the seat of scars and stenoses ; the 
position of the vaginal portion, whether, as usual, in the 
interspinal line or directed backward and upward — a con- 
dition which is of no consequence in the beginning of 
pregnancy, but may constitute a serious obstacle to labor 
at term if the uterus has been fixed too high in the oper- 
ation of vaginovesical fixation — or whether it is directed 
forward toward the symphysis early in the course of 
pregnancy. This would point to the probable existence 
of retroflexion or bending backward of the uterus, nar- 
mally directed forward (see Figs. 17 and 32), under the 
sacrum and into Douglas' pouch (Figs. 18 and 102). 

The following points are of especial importance in con- 
nection with pregnancy and labor : 

The Portio Vaginalis. — Up to the eighth month the 
vaginal portion of the cervix in a prwiigravida feels like 
a hard, conical projection with a round depression, the 
internal os, at the summit ; at this time it apparently 
becomes shorter, being covered by the hypertrophied folds 
of the vagina, and disappears during the last few wrecks 
in consequence of the dilatation of the os. In maltigravidce, 
on the contrary, the lips of the internal os persist, being 
broader than the cervix, wliich feels like a soft fragment 
of tissue lying between folds of the vagina. It forms a 
transve)^se cleft with notched edges. 

During the earlier months of pregnancy the height and 
direction of the portio vaginalis are not changed ; the 



42 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 34. External exaiuiuatiou for the purpose of determining the 
height of the fundus and the position of the fetal back. 

Fig. 35. Locating the head before its engagement in the superior 
strait. 

Fig. 36. After the head has entered the true pelvis. The hands are 
to be pressed downward and inward to reach the true pelvis. 

Fig. 37. Vulva of a Primigravida in the seventh month (original 
water-color from life). — Colchicum color and edema of the nymphse. 

Fig. 38. ColcMcum-colored Fornix of the Vagina from tlie same case. 
— Compare the color with the simple hyperemia of the middle folds of 
the vagina. 



direction of the uterus varies so much with'in physiological 
limits in different individuals that it is impossible to 
give a typical picture. Fig. 32 is an attempt to represent 
approximately the usual position of the non-gravid uterus. 
As soon as the uterine body begins to project above the 
symphysis, which occurs in the fourth month, it is inclined 
forward, the cervix assuming a corresponding backward 
direction (Fig. 19). As the organ continues to ascend, 
the vaginal portion rises above the interspinal line ; the 
external os rests on the j^osteri or fornix near the upper sacral 
vertebrce and is turned toward the left, the body of the 
uterus having its transverse axis in the right oblique diam- 
eter of the pelvis and being directed toward the right The 
latter condition begins in the fourth month. This some- 
times makes it possible to palpate the sound ligament on 
the left side. 

The bladder is drawn upward, so that obstruction and 
dilatation of the ureters and pelves of the kidneys some- 
times occur. 

The OS is usually directed backward and downward 
(sometimes directly backward if the anterior wall of the 
uterus sags), or the cervix may be bent upon the body in 
such a way that the external os looks forward and the 
internal os backward. 

In making a vaginal examination the physician should, 
therefore, ascertain" the position, direction, shape, and con- 
sistency of the portio vaginalis ; the condition and degree 
of dilatation of the (external) os ; and, finally, the disten- 



o 

OS 
H 










^^ 



■^4:^ 




00 ^ 







EXAMIXATIOX. 43 

tion uf the cervical canal and internal os. These 
points are embodied in the follow tahle : 

Differences observed at Term between* 
A Primi(;ravida and a Multigravida. 

Vulva: Closed. Gapes slightly ; scars. 

Vagina : Narrow and rough. Wide, soft, and smooth. 

Portia: Soft, relaxed coui-. Not conical ; soft, edematous mass. 

External os : Round with sharp Open after fifth month : edges not 
edges: closed until ninth month. sharply defined, notched; trans- 
after that admits first phalanx. verse cleft. 

// pervious, labor in a few days. If cervical canal is quite patulous. 

labor in two weeks. 

Internal os : Closed; sometimes Opens during ninth month, 
opens before external os ; opens 
during labor at the same time as 
cervix, and before the external 

OS. 

Position of head at the end of ges- Until the beginning of labor above 
tation within the true pelvis. the superior strait, or but slightly 

engaged in the true pelvis, so that 
it is freely movable. 

During the first three months the size, shape, consistency, 
and position of the uterine body can be ascertained by 
means of bimanual examination, one hand on the abdomen, 
the fino^ers of the other in the vaofiua or rectum. If the 
uterus cannot be felt above the anterior fornix, and the 
vaginal portion is in contact with the pubic symphy.sis, 
there is retroflexion, which may, and usually does, correct 
itself spontaneously as pregnancy progresses. It is better 
practice, however, to replace a retroflexed uterus, because 
the procedure incidentally reveals the presence of any 
inflammatory adhesions in Douglas' pouch. 

A characteristic sign in the early stages of pregnancy is 
the doughy softness in the region of the internal os — Hegar's 
.-ign. It forms a conspicuous area of relaxation, separating 
the hard, globular uterine body, distended l)y the ovum, 
from the cervix, which does not lose its hardness until 
later. 

In the bimanual examination the physician should search 
for other abnormalities, such as tumors of the orenitalia or 
their adnexa, or of neighboring organs, malformations of 
the uterus or vagina (double vagina, septa, etc.), inflam- 



44 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 

Fig. 39. Usual Position of Portio Vaginalis, directed obliquely back- 
ward and downward, in a multipara at term. — The external os is open ; 
the head has not yet entered the true pelvis ; second vertex presentation 
(back on the right side, E. O. A.). Digital method of measuring diagonal 
conjugate (from the lower border of the sj'mphysis to the promontory of 
the sacrum). (Original drawing.) 

Fig. 40. The Head has Entered the True Pelvis (at term ) and is Push- 
ing the Anterior Lower Uterine Segment downward; the Portio Vagi- 
nalis is directed Upward and Backward. — Primigravida, first vertex 
presentation (L. O. A.). It is often difficult in these cases to reach the os; 
the finger should be bent at the distal joint (original drawing). 

Fig. 41. Anterovertical Position of the Portio Vaginalis in a primi- 
gravida at term. — The head is engaged in the superior strait ; cervical 
canal still closed (original drawing). 

matory processes, abscesses, extravasations in Douglas' 
pouch, etc. The uterine artery can usually be felt pul- 
sating through the vaginal wall. Examination of the 
portio vaginalis and of the walls of the vagina with a 
speculum is useful only in the beginning of pregnancy ; 
it shows the wine-veast or colchicum color of the parts 
(see Figs. 37 and 38). 

From the beginning of the fifth month the parts of the 
fetal body can be distinctly felt, and fetal movements as well 
as the fetal heart-sounds, lW-150 double beats per minute, 
can be heard. In this month the dilatation of the external 
OS begins in multiparse. A more accurate calculation of 
the duration of pregnancy now becomes possible. 

At the end of pregnancy our calculations as to the oyiset 
of labor are based on the state of the cervical canal, the 
position of the head relative to the superior strait, the size 
of the child, and the level of the fundus. 

The general ride for calculating the termination of preg- 
nancy is to count back three months from the date of the 
last menstruation and add from seven to ten days. The 
'^average duration " of pregnancy is tw^o hundred and 
sixty-five to two hundred and eighty days ; but there are 
well-authenticated cases in which tlie duration was three 
hundred days and over, a circumstance which is sometimes 
important in a medicolegal point of view. Occasionally 
an ovum discharged during the preceding period is fertil- 



CM 
(M 



(73 




:§^ 



<; 



DIAGNOSIS OF PREGNANCY. 45 

ized, but this is rare ; the impregnated ovum usually dates 
from the time of the first menstruation missed. The 
great vitality of the spermatozoa makes conception possible 
even when there is an interval of a week or more between 
menstruation and coitus. Lastly, it must be borne in 
mind that ovulation may take place in the intervals 
between the menstrual periods. 

To recapitulate, the (.Jlagnostic signs of pregnancy are : 

(a) Probable signs, derived from the mother and ema- 
nating from her generative organs, as : livid color of 
nympha? ; relaxation of the vaginal portion of the cervix 
and characteristic softening of the internal os ; increased 
secretion in the cervical canal, which becomes dilated in 
the fifth month in multiparse ; globular enlargement of 
the uterine body in the sagittal diameter; enlargement of 
the mammary glands due to beginning secretion (serous 
from the second month on) and swelling of glandular 
acini, which radiate in thickened cords from the nipple to 
the periphery ; enlargement of the abdomen, stride (reddish 
if recent, in nmltiparse alternating with whitish scars, due 
to stretching of the elastic tissues and parallel displacement 
of subcutaneous fibers), pigmentation in the median line 
of the abdomen ; cessation of the menses ; uterine bruit. 

The greater number of these signs may be observed in 
inflammatory conditions, circulatory disturbances, and 
with tumors of the generative organs ; for instance, milk 
secretion of the mammae. 

[b) Positive signs belonging to the child, as : palpation 
of fetal parts and fetal movements ; auscultation of the 
latter, of the fetal heart-sounds (120-150), and of the 
synchronous funic souffle. 

The most typical of the unreliable signs are : morning 
sickness ; vertigo ; irregular stools (constipation and diar- 
rhea) ; frequent micturition ; edema and varicose conditions 
of the lower extremities ; various forms of neuralgia. 
These symj^toms are more pronounced in neuropathic 
subjects, and especially in twin and extra-uterine preg- 
nancies. Pigmentation of the face, hollow eyes and cheeks, 
and psychic alterations are also to be mentioned. 



46 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY. 



In addition to these general phenomena we find corre- 
sponding changes in all the organs of the body durimr 
pregnancy. For the purpose of comparison the following 
table has been compiled, to shoAV the changes incident to 
the pregnant state and the retrograde changes observed in 
the puerperium : 



Alterations in the Non-sexu 
and in the 
Pregnancy. 

Bladder : Displaced upward, com- 
pressed ; increased desire to urinate 
or frequent micturition ; ureters 
and pelvis of kidney dilated, de- 
generation of renal epithelium. 

Urine: Quantity increased, spe- 
cific gravity lower, contains albu- 
min, and sometimes sugar (the 
kidney of pregnancy ; the urine must 
always be examined) ; kidneys, liver, 
spleen, and thyroid gland hypertro- 
phied. 

Heart: Left ventricle probably 
hypertrophied (the pulse is more 
rapid, and a difference is observed 
when the patient changes from a 
recumbent to a standing posture, 
which is possible only after com- 
pensation has been established). 

Blood: Hydremia and leukocyto- 
sis; during the first half of preg- 
nancy the number of red blood- 
corpuscles is diminished (lience the 
hydremia) ; hemoglobin increased. 



AL Organs during Pregnancy 
Puerperium. 

Puerperium. 

Urine: Quantity diminished on 
the first and second day ; minimum 
is reached on the fourth day, after 
which it begins to increase ; con- 
tains lactose, acetone ; percentage 
of nitrogen in proportion to amount 
of milk secretion (greatest, there- 
fore, from the third to the fifth 
day); peptonuria (due to breaking 
down of uterine muscle ; also found 
in the lochia; absent after amputa- 
tion of uterus) ; pepsin. 

Pulse 1 .• Often falls to 40-60 imme- 
diately after delivery and is soft; 
this does not by any means occur 
in all cases, as was formerly sup- 
posed, perhaps not even in the ma- 
jority ; idiosyncrasy plays the most 
important role. 

Leukocytosis disappears ; number 
of red blood-corpuscles unchanged, 
hemoglobin diminishes in the first 
few days. Toward the end of the 
lochia serosa (seventh day) both red 
and white blood-cells are increased. 
At this time many microcytes and 
small, highlj' refractive elements 
are seen. 

1 Various reasons are given for the remarkable diminution in the pulse- 
rate so often observed after childbirth, such as alteration in the blood- 
pressure, the mental and physical rest in the horizontal position and 
collapse of the abdomen (hence stasis in the abdominal veins, less blood 
in the heart and lungs, fall of blood-pressure), the slowing of the respi- 
ration, ^ew^raZ retardation of all the functions — pulse-rate diminished during 
inspiration (sucking action of lungs in the pleural cavity ; the lung 
capacity rises on the third to the fifth day). Other theories, as absorp- 
tion of the fatty uterine muscle, disturbances of innervation, less demand 
on the heart, etc., appear to be refuted by the facts that the same reduc- 
tion in the pulse-rate is observed after abortions, or as early as thi'ee 
hours postpartum, and that the urine is increased in amount. The 
reduction in the pulse-rate is rarely observed in neuropathic women. 



DIAGNOSIS OF PREGNANCY. 47 

Lungs: Widely separated from Vital lung capacity increased on 

each other, diaphragm higli. thorax the third daj'^. 
expanded laterally and sagittal di- 
ameter diminished. Vital capacity 
unchanged. 

JiDier table of sic nil : Osteophytes. 

Gums hypertrophied. 

St//i ;' Increased secretion, chlo- 
asmata. 

Plilebectasix in the lower extrem- 
ities. 

Intestine: Much constipation, at Physiologic constipation till the 

first diarrhea; hemorrhoids. third or fourth day (size of stools 

increases when meat-diet is taken). 

The following points are important in the differential 
diagnosis of pregnancy from other conditions : 

1. Menstruation persists and is, as a rule, increased in 
metritis, myoma of the uterus, and ovarian cysts. There is 
no change in the patienfs condition. If there is a tumor 
and menstruation ceases, the neoplasm is usually found to 
be attached to the uterus by a distinct pedicle, consisting 
of the tube and ovarian ligament, and the question of 
ectopic gestation must be considered. 

2. In heniatonietra menstruation is absent from the start. 
On examination with the speculum and uterine sound the 
cervix is found to be occluded, the menstrual blood being 
collected above the cervix within the uterine body or in 
the tubes. (Great care must be observed in the combined 
examination.) 

3. Para- and perimetritis give rise to febrile attacks, 
which should be inquired for ; the examination \t: attended 
with great pain. 

4. In retroflexion there is a characteristic anterior dis- 
placement of the vaginal ])ortion of the cervix and the 
anterior lip of the os is much attenuated. The portio 
vaginalis itself is hard ; the uterine body cannot be felt 
above the anterior fornix. The differential diagnosis is 
often very difficult, as a retroflexed uterus is apt to become 
excessively swollen and soft. If the pain continues severe 
and menstruation is persistently absent (with retention of 
urine), the possibility of pregnancy in a retroflexed uterus 
should be considered. 



48 PHYSIOLOGY AND DT A GNOSIS OF PREGNANCY. 

5. In retro-uterine hernatocele a HuctLiatiiig tumor is felt 
in Douglas' pouch, arching the posterior fornix downward 
and merging directly into the uterine body without the 
interposition of a pedicle. The pain comes on suddenly, 
since this form of intraperitoneal hemorrhage is almost 
exclusively caused hy the rupture of a gravid tube — in 
short, a tubal pregnancy. 

6. The physician should always bear in mind how often 
such conditions as a distended bladder, obesity, showing 
itself in greatly thickened abdominal walls, meteorism, and 
constipcdion have led to an erroneous diagnosis of preg- 
nancy, especially when the woman herself is firmly con- 
vinced that she is pregnant, menstruation is absent, and 
the breasts become enlarged and even begin to secrete. 
In neurotic individuals such imaginary conditions quite 
frequently occur (spurious pregnancy, grossesse nerveuse). 

7. Particular attention should be given to the diagnosis 
of a dead fetus in utero, especially during the period when 
the fetal parts cannot be recognized by palpation. Fetal 
heart-sounds and movements are absent; from the history 
it is learned that probable and unreliable signs of preg- 
nancy were present, but that the typical enlargement of 
the abdomen has ceased and the swelling in the breasts has 
subsided. The woman complains of frequent chills (ab- 
sorption). The dead fetus is often retained within the 
uterus several months, undergoing maceration, mummi- 
fication, or total absorption. 

So far we have been engaged in discussing the internal 
examination of the soft parts, but the examination of the 
pelvis itself is never to be neglected in any case of preg- 
nancy. At least it should be ascertained that there is no 
contraction, that no marked asymmetry exists, and that 
the walls are free from exostoses or osteomata. In general 
terms it may be said that the jx'lvic cavity should be large 
enough to accommodate a man's fist comfortably, or, to be 
more accurate, if an internal examination is made with 
the index and middle fingers, the promontory should be 
almost or quite beyond the reach of the middle finger (see 



DIAGNOSIS OF THE NORMAL FEMALE PELVIS. 49 

Fig. 39). It is then certain that the usual form of con- 
traction, in the sagittal diameter called '^conjugata/' is not 
present. We then satisfy ourselves by palpating the lateral 
and anterior walls of the pelvis that there is no lateral dis- 
placement or inward projection of the pelvic bones, noting 
whether there is abnormal tenderness. Finally, we must 
not forget to estimate roughly with the fingers the dis- 
tances between the spines and the tuberosities of the 
ischium, corresponding to the pelvic outlet. A cursory 
survey of the entire skeleton, including the angle of the 
false pelvis, will suffice to detect any signs of rachitis. 

A detailed examination of the pelvis by means of 
measurement necessitates an accurate knowledge of the 
different varieties of deformed pelves. 



CHAPTER 11. 



ANATOMY, DEVELOPMENT, AND EXAMINATION 
OF THE PELVIS. 

§ 3. DIAGNOSIS OF THE NORMAL FEMALE PELVIS. 

The genital tract is contained in the pelvis and sup- 
ported by it ; in the later months of pregnancy it rests 
partly upon the pelvis. The characteristic shape of the 
female pelvis is determined partly by the erect attitude of 
the individual, partly by the pregnant and parturient 
genital apparatus. The male pelvis presents only those 
qualities which depend on the erect attitude, the female 
pelvis is, therefore, more specialized, although not so 
robust ; it may be roughly described as more roomy and 
more expanded laterally. 

^y ins2:)eetion and j^cdpcttion we determine whether the 
shape is symmetrical (for instance, obliquely distorted or 
with one iliac bone higher than the other) ; the woman is 
examined in a standing posture or lying on her back. 
We satisfy ourselves that there is no kyphosis, lordosis, 

4 



50 ANATOMY AND EXAMINATION OF PELVIS. 

Fig. 42. Measurement of tlie Transverse Diameter of the Outlet 

(after Breisky) : 10, tuberosities of the ischia; 7a, anus; 20, introitus 
vaginae. 

Fig. 44. Accurate Measurement of tlie True Conjugate with the Pel- 
vimeter (after Skutsch). — With this instrument, which can be easily 
bent in any direction, the examiner first measures the distance between 
the promontory and the external surface of the symphysis (continuous 
lines), and then tlie thickness of the latter (broken lines), introducing 
one branch of the instrument through the vagina, the bladder having 
been previously evacuated. The difierence between these two measure- 
ments is the true conjugate. 

Fig. 45. Measurement of the External Conjugate (diameter of Bau- 
delocque) with the Baudelocque-Martin Pelvimeter (Fig. 43; original 
drawing). — Measure from the upper edge of the symphysis, compressing 
the overlying fat, to the spinous process of the last lumbar vertebra in 
the deepest part of the rhomboid fossa. 

Fig. 56. Accurate Measurement of the Transverse Diameter of the 
Inlet with the Same Instrument. — First ascertain the distance from the 
iliopectineal line (extremities of transverse diameter) to the outer sur- 
face (trochanter) of the opposite thigh (continuous .lines), and subtract 
the distance from trochanter to iliopectineal line on the same side 
(broken lines) ; the result represents the transverse diameter of the pel- 
vic inlet. 



or scoliosis of the vertebral column. Attention should 
be given to the general build of the patient, whether she 
is rachitic or dwarfish in stature; to the shape of the 
head, whether square with high frontal eminences ; and 
to the shape of the chest (chicken-breast) and legs (bow- 
legs). If the distance between the two anterior superior 
spines of the ilium can be spanned with the outstretched 
hand the pelvis is contracted. This distance, from thumb 
to little finger on an average man's hand, is about 9J in. 
(2:3 cm.). 

The following external measurements are taken with the 
Baudelocque-Martin pelvimeter (see Figs. 43 and 45) : 

1. The distance betiveen the anterior superior spines, 
lOJ in. (26 cm.) in the living subject; 9^ in. (24 cm.) in 
the skeleton. Place the knobs of the pelvimeter firmly 
against the spines. 

2. The distance between the crests of the iliac bones, 
11 J in. (28 cm.) in the living subject; lOf in. (27 cm.) 



Tab. 23. 





Fig. 42. 



Fig. 43. 




Fig. 44. 



Fig. 45 



Lith.Anst E RetcfOwld, MCuiciien 



DIAGNOSIS OF THE NORMAL FEMALE PELVIS. 51 

in the skeleton. Measure between the two points most 
widely separated. 

3. The (Uainder of Baudelocque (external conjugate), 
7 J in. (19.5 cm.) in the living subject; 7J in. (18 cm.) in 
the skeleton. This diameter corresponds to the distance 
between the spinous process of the fifth lumbar vertebra 
and the upper edge of the symphysis pubis.^ 

4. The transverse diameter of the pelvic outlet^ Z\ to 4 in. 
(8 to 10.8 cm.) in the living subject; 3^ to 3f in. (8 to 
9.2 cm.) in the skeleton. Place the woman in the lithot- 
omv position and measure between the inner edges of the 
tuberosities- (see Fig. 42). 

And in deformed pelves :^ 

5. The external oblique diameter, 9 in. (22.5 cm.) in 
the living subject ; 8^ in. (21.5 cm.) in the skeleton ; from 
posterior superior spine to anterior superior spine of the 
opposite side. Both diameters should be measured. 

6. The anteroposterior diameter of the pelvic outlet (con- 
jugate of pelvic contraction), 4 to 5^ in. (10 to 14 cm.) 
in the living subject; 4^ in. (11.5 cm.) in the skeleton. 
Sims' position ; from the lower extremity of the sacrum 
to the lower border of the symphysis. 

7. The intertrochanteric distance, in the living subject, 
12^ in. (31 cm.). Place the knobs against the outermost 
points of the trochanters, the legs being extended. 

8. The distance between the posterior supei'ior spines, in 
the living subject, 3|- in. (9.8 cm.). Place the knobs in 
the dimples on either side of the spine. 

9. The circumference of the pelvis, in the living subject, 
36 in. (90 cm.). Measure witK the tape from the sym- 
physis to the middle of the sacrum along the lower border 
of the ilium and back on the other side. 

1 The spinous process of the last lumbar vertebra is the second process 
felt above the line joining the two dimples which mark the position of 
the two posterior superior spines, at the deepest point of the rhomboid 
fossa. 

2 Klien's instrument is a useful one for this measurement. 

3 See, also, under generally, obliquely, and transversely contracted and 
compressed pelres. 



52 ANAT03IY AND EXAMINATION OF PELVIS. 

Fig. 46. Palpation of the Spines of the IscMum after the head has 
descended (original drawing). — The head is completely engaged in the 
true pelvis and "immovable." The cervical canal is "obliterated," 
being completely filled by the head ; the external os is about as large as 
a half-dollar. The sagittal sutui'e coincides with the right oblique 
diameter; the largest diameter of the head is below the inlet in the 
plane of greatest expansion. (The red lines show" the contour of the 
pelvis; for numerals, see Index). 

Fig. 47. Sagittal Section througli a Fetal Pelvis. — The red lines rep- 
resent the soft parts. 

Fig. 48. Sagittal Section througli the Fully Dilated Birth- canal 
Represented Within the Pelvis ; the soft parts are stretched to their 
utmost (for instance, 14, perineum). The resistance offered by the bony 
and soft parts is indicated by arrows. The direction taken by the 
advancing head as it emerges is also shown by a curved line of arrows 
(the curve of Carus). The coccyx (3) and the jjerineum are forced back- 
imrd. The axis of the pelvic canal passes through the centers of the 
conjugates of all the pelvic planes. Its curve is determined by the con- 
cavity of the sacrum and coccyx on the one hand, and by the greater height 
of the posterior wall of tbe pelvis compared to the anterior, i. e., the 
symphysis (1) ; 40 and 41, tuberosacral and ischiosacral ligaments. 

With the exception of the fourth, these measurements 
have only a relative value. For instance, the distance 
between the spines should be less than that between the 
crests. In the rachitic pelvis tliis relation is reversed. 

By subtraction w^e estimate approximately the following 
more important internal measurements ; 

The distance between the crests minus about 5f to 6 in. 
(14.1 to 15 cm. [4f to 5 in. = 11.5 to 12.5 cm. in flat 
pelves]) is equal to the transverse diameter of the inlet, 
5i in. (13.5 cm.). 

The oblique diameter minus about 4 in. (10 cm.) — the 
right is normally somewhat longer than the left^ — equals 
the oblique diameter of the inlet, 5 in. (12.5 cm.). 

The external conjugate minus 3^ to 3f (8 to 9 cm.) 

1 The normal pelvis presents a slight scoliosis toward the left side, 
hence the right oblique diameter, from the right sacro-iliac articulation 
to the pubic spine of the opposite side, somewhat exceeds in length the 
left oblique diameter at tbe inlet; tlie right half of the pelvis is some- 
what flattened and tbe sacrocotyloid distance on that side is shorter 
than on the other. The external diameters usually bear the same rela- 
tions to each other as the internal, especially if the difference is great. 



DIAGNOSIS OF THE NORMAL FEMALE PELVIS. 53 

equals the true conjur/afey 4.V in. (11 cm.). If tlio external 
conjno:ate is 6^ in. (16 cm.) or less the pelvis is certainly 
contracted ; if 7^ in. (18 cm.) it is contracted in half the 
cases. 

The followinir hiternal measurements are actually made : 
The d'uujoudl conjugate,^ 5 in. (12.5 cm.) minus | in. 
(1.5 cm.) — in flat rachitic pelves, f to 1 in. (2 to 2.5 cm.) — 
the conjugata vera, 4|- in. (11 cm.), from the lower border 
of the symphysis to the promontory. The index and 
middle lingers are inserted into the vagina, with the 
thumb placed against the symphysis and the other two 
fingers folded into the palm, and the promontory is felt 
with the middle finger (Fig. 39). The examining finger 
is then swept along the curve of the iliopectineal line to 
detect any points of abnormal resistance, asymmetry, or 
exostoses, especially at the so-called synchondroses or 
points where the several layers of fetal bone become 
fused. 

The measurements of the inlet can also be accurately 
determined with the aid of instruments, after Skutsch 
(see Figs. 44 and b^). 

Skiagraphy naturally suggests itself as an aid to pelvimetry, 
particularly as only a few minutes' exposure is necessary for the 
purpose. In fact, it is possible not only to obtain a clear picture 
of the pelvis but also to measure certain distances. Radioscopy 
alone (with the screen) gives a more or less satisfactory picture in 
the non-pregnant woman ; it is best to use the plate in the dark 
chamber. The woman is placed on her back and the plate pushed 
well under the buttocks, so that it projects 2 in, (5 cm.) beyond 
the vulva. These skiagraphs are particularly useful in the diag- 

^ The diagonal conjugate is the distance between the lower border of 
the symphysis and the promontory. From it we calculate the true con- 
jugate, which does not, however, lie exactly in the plane of the pelvic 
inlet, as the latter cuts the sacrum below the promontory. If, when the 
woman is examined in the dorsal position (Figs. 39, 55), the promontory is 
bej'ond the reach of the middle finger, the diofjonal coujufjnte exceeds 4§ in. 
(11.5 cm.) ; if the buttocks are raised, as in Fig. HI, it is 5 to 51 in. (12.25 
to 13 cm.). A similar increase in the length of the conjueate occurs in 
Watcher s posture (Fig. 62), which is, therefore, a useful position in labor 
when the pelvis is contracted. On the other hand, the conjugate of the 
outlet is shortened by the Walcher posture and increased by the lithotomy 
position. 



54 ANATOMY AND EXAMINATION OF PELVIS. 

nosis and mensuration of asymmetrical pelves ; they furnish the 
following measurements : 1, The distance between the posterior 
superior spines ; 2, the width of the sacrum ; 3, the distance from 
the lumbosacral crest of the spine to the posterior superior spine 
of the ilium ; 4, the distance from the middle of the promontory 
to the sacro-iliac articulation. 

The tratisverse diameter of the outlet is obtained from a photo- 
graph taken in the sitting posture, deducting f in. (2 cm.) for the 
thickness of the soft parts. Finally, one can ascertain the curve 
of the pubic arch and the transverse diameter of the pelvic inlet. 

Dimensions of the Individual Portions of the 
Normal Female Pelvis. — The false pelvis is formed 
by the iliac bones and the last two lumbar vertebrae ; its 
dimensions correspond to the distances between the various 
points of the iliac bones^ which have just been given. It 
supports the intestines and, after the fourth month of ges- 
tation, the body of the uterus. 

The true pelvis begins at the pelvic inlet, in the plane 
which passes through the promontory and the upper edge 
of the symphysis, encircled by the iliopectineal line. The 
posterior wall of the true pelvis is formed by the sacrum, 
the lateral and anterior walls by the ischium and pubis. 
The ascending and descending rami of these bones enclose 
the obturator foramen and, with the iliac bone, form the ace- 
tabulum for the reception of the head of the femur. In 
girls between twelve and fourteen the triradiate figure of the 
synchondrosis can be seen on the floor of the acetabulum. 
The open space between the sacrum and ilium (ineisura 
ischiadica) is traversed by two strong bands, the tubero- 
sacral and ischiosacral ligaments. The sacro-iliac joint 
(formed by the "auricular^' cartilages) and the symphysis 
pubis are strengthened by capsules and ligaments. The 
so-called anterior wall of the pelvis is very narrow, being 
formed by the two pubic bones, the rami of which, with 
the rami of the ischium, form the pul)ic arch. 

The cavity of the true pelvis presents several planes of 
varying dimensions (see Figs. 48, 55, 70-72). The plane 
of the inlet ; the plane of greatest pelvic expansion between 
the middle of the body of the third sacral vertebra and 



DIAGNOSIS OF THE NORMAL FEMALE PELVIS. 55 

the middle of the symphysis, its lateral boundaries being 
the great sacroseiatic notch and the wall of the acetabulum ; 
the plane of least pelvic expansion, passing through the 
riixid sacrococcygeal articulation, the ischial spines, and 
the lower border of the symphysis (the intcrspindl line in 
this plane corresponds with the smallest diameter of the 
pelvis) ; and the plane of the outlet, which is concave, as 
its boundaries occupy different levels : the movable tip 
of the coccyx and the lower border of the symphysis 
and, on a lower level, the tubera ischii. 

Xot only does the same diameter vary in the different 
planes, but the relations between the various diameters 
also vary, so that each plane has a different shape. Con- 
siderable difiPerences are noted not only in different races 
and peoples but also in individuals. The oblique diame- 
ters are the most constant of all the diameters at the inlet, 
while general contractions, and especially a shortening of 
the true conjugate, are for some unknown reason observed 
most frequently in certain planes (rachitis). 

Con JUG ATA Yeea. 

{between promontory 
and upper border of 
symphysis.^ 
( tbird sacral vertebra 
In the plane of greatest expansion. 5 in. (l'2.5em.) < to middle of symphy- 

( sis. 

( sacrococcygeal articu- 
In the plane of least expansion, 4f in. ill.5 cm.) -, lation to lower border 

( of symphysis. 
., ,, .1 . , . «•? . /-inj- n \ f tip of coccTx to lower 

Attheoutlet. 4to4jin. (10tol2cm.) ..... border of symphysis. 

Transverse Diameter. 

[ greatest distance be- 

At the inlet. o\ in. 1 13.5 cm. i tween iliopectineal 

( lines. 

T .V 1 /. . . . 4^ • ,n . I distance between ace- 

In the plane of greatest expansion. 4$ in. (12 cm. i tahnla 

T ., 1 ^ 1 X • . • -i,-. ' distance between is- 

In the plane of least expansion. 4 in. 1 10 cm.i . rhial snines 

.. ., 4.1 J. 49 • /1-1 \ ' distance between tu- 

At the outlet. 4f in. (11cm.) bera i.^chii. 

1 The obstetric conjugate of the inlet is situated i in. (i cm.) lower. 



56 ANATOMY AND EXAMINATION OF PELVIS. 

Fig. 49. Normal Female Pelvis in erect posture (front view ; original 
drawing from a specimen in the Munich Gynecological Clinic). 

Fig. 50. Generally Equally Contracted Pelvis, practically a miniature 
reproduction of the normal pelvis, with, however, certain infantile char- 
acteristics. The iliac bones are relatively and absolutely smaller, the 
promontory is less prominent (original drawing from a specimen in the 
Munich Gynecological Clinic). 

Fig. 51. Greatly Contracted Funnel- shaped Pelvis (" Liegbecken," 
decubital pelvis) Approaching the Fetal Form (see '0^ 4 and 19).— The 
sacrum is straight, the iliac bones are small and fiat, the pelvic inlet 
is more circular than normal, and there is marked contraction at the 
outlet, the result of years spent in bed, from infancy until death, which 
occurred about the age of puberty. The weight of the trunk, the 
counter-pressure of the thighs, and the action of the muscles are 
eliminated (original drawing from a specimen in the Munich Gyneco- 
logical Clinic). 



Oblique Diametek. 

( sacro-iliac articulation 

At the inlet, 5 in. (12.5 cm.) < to iliopubic tubercle 

(, of opposite side. 

{great sacrosci ati c n otch 
to obturator sulcus of 
opposite side. 
T X 1, 1 ^ 1 J- -1 r extensible, because 

In the plane of least expansion t bounded by liga- 

^t *^^ '^"t'^^* ' 1 ments. 

The importance of examining the pelvis before giving 
a prognosis of the probable conrse of labor has just been 
emphasized. 

^ 4. SHAPE AND INCLINATION OF THE ADULT 
FEMALE PELVIS AND ITS DEVELOPMENT. 

The normal adult female pelvis as contrasted with the 
male has a large transverse diameter. Three factors enter 
into its development from the fetal ])elvis : 

The formation of the promontory ; 

Lateral expansion ; 

Disappearance of the funnel shape. 

A knowledge of the structure of the fetal pelvis and 
its subsequent development up to the age of puberty is 



Tab. 25. 




Fig 51 



Lith. Ansi E Retchhald, Miimhm,. 



siiArr: of Anri/r female fflvjs. 57 

necessary tor the comprclicnsion of the various foi'ins of 
pelvic deformity. 

The sluipe and inclination of the pelvis are determined by the 
action of three forces: the weight of the trunk, the coinUrr-jjrcsHure 
of the thi(/hfi, and the resi.<<ta?ice ofiered by the xiiiiijjhij.^ix, and by 
three developmental factors : 

1. A forward movement analogous to the anteflexion of the uterus. 
The promontory falls forward as a result of the superincumbent 
weight of the trunk (cf Fiir. 53 with Figs. 54 and 55); the 
sacrum is beni and pushed uj)ward and backward ; the ilia and 
the upper part of the sacrum rotate forward ; tiie loicer border of 
the symphysis, which in the fetus projects forward, moves in the 
opposite direction, backward.^ 

2. The first developmental moxement is almost compensated for 
by a second, which forces the portion of the pelvis in front of the 
great sciatic notch upward, the most anterior portions (toward the 
symphysis) being most affected. This is the result partly of the 
pressure of the thighs (cf Figs. 52, 53, 57 wdth the ''decubital 
pelvis," Fig. 51), partly of the inherent hereditary tendency of the 
right horizontal ramus of the pubis to undergo rapid growth, and 
thus produce a lateral expansion of the pelvis, to which among 
other factors the sacro-iliac ligaments also contribute (No. 32 in 
Fig. 57) by drawing the iliac bones backward. Up to the fifth 
year this movement plays an important role, owing to the softness 
of the bones, the transverfte diameter being affected more than the 
anteroposterior. 

3. x\ slight scoliosis of the pelvis to the left occurs as a result 
of hypertrophy of the right horizontal ramus of the pubis and 
adjoining portion of the acetabulum, and of the left ala of the 
sacrum and iliopectineal line ; the svmphvsis is displaced to the 
left. 

As a result of the two movements described under 1 

^ This movement, the result of the characteristic wedge-shaped growth 
of the hambar and sacral vertebrje (and the consequent formation of the 
promontory), is directly dependent on heredity and the erect posture in 
walking. The tendency begins in the embryonal and fetal period, but 
its completion is brought about in each individual by the exercise of his 
functions. The angle of the femur with the long axis of the vertebral 
column in the fetus, in the new-born, and in tlie adult is found to be 
respectively 1.30, 1G2, and 19.") degrees, showing that there is a gradual 
movement backward on the part of fennir. pelvis, and sacrum. This 
movement is effected by the extensor muscles of the vertebral column, 
the sacrospinal muscle (see Figs. .53 and 54) ; note the military hyper- 
extension of the pelvis in Fig. 54. The influence of muscular action on 
the shape of the pelvis and of the bones in general has been proven 
experimentally by dividing the muscles in young animals and observing 
the subsequent abnormal development of the bones (Kehrer). 



58 ANATOMY AND EXAMINATION OF PELVIS. 

Fig. 52. Female Fetal Pelvis in erect posture (front view ; original 
drawing from author's specimen). — The sacrum is almost straight; the 
promontory projects very little. The uncolored surfaces represent the 
cartilaginous portions that have not yet undergone ossification. The 
pubic arch forms a right angle. 

Fig. 53. Sagittal Section through a Fetal Pelvis, showing the Angle 
of the Femur with the Spinal Axis.— The peculiarities of a fetal pelvis 
described in the foregoing figure appear even more plainly in this one. 

Fig. 54. The Same in the Adult.— The promontory has fallen forward ; 
the sacrum is pushed upward and backward ; the position of the sym- 
physis is more posterior than in the fetus. 

and 2, the pelvic angle ^ in the adult woman measures from 
50 to 55 degrees, in an easy, erect posture with the legs 
parallel to each other. The angle varies from 40 degrees 
in a stiff, military attitude, or the attitude of a pregnant 
woman, to 100 degrees in the recumbent posture with the 
trunk bent over in front and the knees drawn up (" ano- 
dorsal position ^^ [see Fig. 61], i. e., lithotomy position). 
On account of this wide variation the measurement has 
no obstetrical value, although it is interesting from an 
anthropological point of view ; but the 'pradical bearing 
is of the greatest value as determining the best positions 
for the various obstetrical and gynecological processes and 
operations. We shall return to this later. 

The changes in the pelvis incident to its development are given 
in the following comparative table, and serve to explain deformi- 
ties due to arrested development or to pathological conditions in 
infancj^ : 

Fetal Pelvis. Adult Female Pelvis. 

Difference between sexes distinct 
in the fourth month (Fehling). 

8m.all transverse diameter, from Large transverse diameter. 

the third month on. 

Conjugate vera: transverse di- 
ameter = 100 : 105-108 =100:122. 

Promontory very hifih, lumbosa- Promontary projects /oeiDard! and 

cral convexity very slight. into the pelvis, lumbosacral con- 

vexity angular. 

1 By pelvic angle is meant the angle formed by the plane of the pelvic 
inlet, or the true conjugate, with the horizon when the body is in the 
erect posture ; in this posture the symphysis is lower than the promon- 
tory. The height of the posterior wall of the pelvis (promontory to tip 
of coccyx) is 5i in. (13 cm.); that of the anterior wall (symphysis) is If 
in. (4 cm.). 



Tab. 26. 




LWv.Anst E R£icfLlwUi,Mmicheri. 



SHAPE OF ADULT FEMALE PELVIS. 



59 



Angle of pelvic inlet = 75 to 80 
degrees 

Sacrum and coccyx almost verti- 
cal and straight. 

Sacrum tlat from side to side ; 
bodies of vertebrae larger than alee 
and cuboidal (posterior and anterior 
borders at the same level). 

Sacrum relatively narrow. 

Pubic arch = 70-90 degrees. . . 

All the diameters of the true 
pelvis are relatively much smaller 
than in the adult female pelvis 
(corresponding, therefore, to the 
"funnel-shaped" contracted pel- 
vis). 

Iliac bones narrow, steep, and 
flat. 

Angle of iliac bone v^ith ilio- 
pectineal line = 155 degrees . . . . 

Tubera ischii at outlet nearer to- 
gether than spines. 



= 55 to 60 degrees.^ 

Sacrum and coccyx vertical and 
concave. ■■^ 

Sacrum concave from side to side ; 
bodies of vertebrae just as large as 
the ake ; anterior and posterior 
borders wedge-shaped. 

Sacrum relativelv very broad. 
95-100 degrees. 

All the diameters of the true 
pelvis considerably larger com- 
pared with the true conjugate, 
especially the transverse and ob- 
lique diameters. 



Iliac bones broad, 
ally, and concave. 



inclined later- 



= 125 degrees. 

The distance between the spines 
of the ischium represents abso- 
lutely the shortest pelvic diameter. 



^ If by means of Chrobak's apparatus the mean inclination of the ex- 
ternal (Baudelocque) diameter is found to be 46.6 degrees, and that of 
the true conjugate 51.8 degrees, the mean difference will be in a normal 
pelvis 5.18 degrees, in a "large" pelvis 8.8 degrees, in the simple flat 
pelvis still greater — 12.9 degrees, while in the rachitic flat pelvis it may 
be less or even negative. Again, it is greater in rachitic non-contracted 
pelves (15-23 degrees), and in generally contracted pelves 12 degrees 
(Savor). 

2 The most dorsally situated portion corresponds to the articulation 
with the auricular surface of the ilium and to the insertion of the com- 
mon extensor muscle of the trunk; the sacral curve is, therefore, to be 
considered as the resultant of these two factors : the weight of the trunk 
and the traction of the extensor muscles of the trunk in the erect post- 
ure. The coccyx is drawn forward by the coccygeal muscle and the levator 
ani, that is, toward their points of insertion : the spines of the ischium 
and the symphysis. The ligaments connecting the spines and tubera 
ischii with the sacrum have the same effect. According to my investiga- 
tions the upper portion of the sacrum is rotated backward through 70 
degrees, the posterior arch of the great sciatic notch the same, but the 
anterior arch rotates only through 40 degrees, that is, the anterior por- 
tion of the true pelvis is not rotated backward as much as the posterior 
portion. As a result, we have the developmental movement described 
above under Xo. 2 : the tilting upward in front and the diminished incli- 
nation of the pelvic inlet in the adult. In the same way the symphysis 
rotates backward only 50 degrees, and as the rotation of the .sacrum is 70 
degrees, the symphysis is raised a distance proportional to the remaining 
20 degrees (see position of symphysis in movement No. 1, this section). 



60 ANATOMY AND EXAMINATION OF PELVIS. 

Fig. 55. Sagittal Section of a Normal Adult Female Pelvis in the 
Erect Posture (original drawing from a specimen in the Munich Gyne- 
cological Clinic). — To show the inclination of the pelvic inlet, that is, 
the relative positions of promontory and symphysis. 

Fig. 56. Measurement of the Transverse Diameter of the Inlet, after 
Skutsch (see explanation of Fig. 44). 

Fig. 57. Effect of the Pressure of the Thighs and the Traction of the 
Iliosacral Ligaments (Weight of the Trunk) on the Shape of the Pelvis : 
32, iliosacral ligaments. 

Fig. 58. Pelvic Angle in the Ordinary Dorsal Position. 

Fig. 59. Pelvic Angle when the Trunk is Raised. 

Fig. 60. Pelvic Angle with the Legs Drawn Up (lithotomy position). 

Fig. 61. Pelvic Angle when the Lumbosacral Region is Raised and 
the Thigh Drawn Up. 

Fig. 62. Pelvic Angle in Walcher's Position with Legs Hanging Down. 

Fig. 63. Pelvic Angle in Semilateral Knee-elbow or Sims' Position. 
(Original drawings.) 

VARIATIONS IN THE PELVIC INCLINATION AND 
THEIR PRACTICAL VALUE. 

In the flat dorsal position with the sacrum slightly sup- 
ported the pelvic inclination is 25 degrees (Fig. 58, " incli- 
nation of decnbital pelvis "). In the dorsal position with 
the trunh slightly raised the inclination is 20 degrees (Fig. 
59) ; in Sims' position with " hollow back," also 20 degrees 
(Fig. 59) ; in tlie lithotomy position (Fig. 60), 30 degrees ; 
in anodorsal decubitus (buttocks raised, loins touching the 
couch, legs drawn up, Fig. 61), 60 degrees. 

The greatest inclination is obtained in the Walcher 
position (the woman lies flat on her back and lets her legs 
hang down over the edge of the couch), with a decubital 
pelvic angle of 10 degrees (Fig. 62), or by the knee-elbow 
position (j^ositiou d la vache), with an angle of 15 degrees 
(Fig. 63), which equals that of Sims' position (semilateral 
knee-elbow position). 

" AYalcher's position " takes its name from its author, 
who recommended its use in the flat (?*. e., anteroposteriorly 
contracted) pelvis, because it increases the length of the 
conjugate from -J- to f in. (^ to H cm.). 

If the head is arrested by the symphysis and fails to 
engage in the true pelvis, or if it is desired to make an 










vO 






ft; 







Tab. 28. 




Fig. 58. 




Fig. 59. 




Fig. 60. 



Lith.Ansl E ReicfUiold, Mimchen . 



Tab. 29. 




Fig. 61 




Fig. 63 



lith.Arhsi EReicfihold.Miinrhm. 



SHAPE OF ADULT FEMALE PELVIS. 61 

internal examination for the purpose of measuring the 
diatronal conjiifrate, the decubital angle may be increased 
bv mi:«ing the buttocks and depres-ing the spinal column 
(Figs. 60 and 61). By this procedure the promontory is 
brouo:ht nearer the examining finger and the conjugate is in- 
creased, being made as nearly as possible vertical to the 
long axis of die fetus and uterus. The latter falls back- 
ward and occupies a plane perpendicular to that of the 
inlet. The \vhole length of the spinal column, especially 
the lumbar region., must l)e firmly pressed against the 
couch. All these positinns tend to relax tlie muscles con- 
nectincr the pelvis and femora, and thereby also dilate the 
birth-canal. Thus, when the head engages in the superior 
strait, AValcher's position is very useful in difficult labors, 
On the other hand, when the head is approaching the out- 
let, that is, during its passage through the vulva and over 
the perineum, the smaller the pelvic angle in the dorsal 
position the nearer will Ije the head to the symphysis and 
the smaller, therefore, the danger of a perineal tear (Tigs. 

51, 60). 

The lithotornij position is tu he u.-ed in nperatiuns on 
the vulva (perineal tears) or on the anterior fnrnix -. on 
the vaginal portion of the cervix (suturing lacerations) 
after a speculum has been introduced (legs flexed on 
abdomen); and when the head engages in the outlet. 

AValcher's position is sometimes useful in celiotomies, 
to facilitate the drawing of a tumor or of the gravid 
uterus into the operative^ field. There are certain modi- 
fications of this position which also tend to throw the 
intestines against the diaphragm and bring the pelvic 
viscera into view, as Trendelenburg's and Yeit's positions 
(the trunk is placed low, either the knees or the pelvis 
forming the highest part of the body). A knowledge of 
the influence of these positions may be of great impor- 
tance in the performance of Cesarean section, Porro's 
amputation of the uterus, and other obstetrical operations 
on the abdomen, labor complicated bv ^m obstructing 
tumor, ectopic gestation, and rupture of the uterus. 



62 NORMAL LABOR. 

CHAPTER III. 

NORMAL LABOR. 

The Forces of Expulsion and Resistance Concerned in the Presenta- 
tion and Expulsion of' the Fetus. Uterine Muscle, Vagina. 
Muscles of the Perineum, Pelvic Planes. 

I 5. THE UTERINE MUSCLE AND ITS FUNCTIONS DUR= 
INQ PREGNANCY AND LABOR. 

The virgin uterus is pear-shaped (Figs. 30-'i2, 64, 77) ; 
it measures 2f to 3^ in. (7 to 8 cm.) in length, 1^ in. 
(3 cm.) in its greatest transverse diameter, and weighs 
1 to 1\ oz. (30 to 40 gm.) ; its walls are thicker than they 
are during the greater part of pregnancy. 

Immediately after delivery a well-contracted, anteflexed 
uterus is somewhat more globular, but ^i\\\ flattened from 
before backward on its posterior surface ; its length is 6| 
to 7^ in. (16 to 18 cm.) ; the thickness at the fundus J to 
\\ in. (2 to 4 cm.); the length of the cavity as determined 
with a sound is about 6 in. (15 cm.) ; the weight is 26 J to 
351 oz. (750 to 1000 gm.). 

During pregnancy the organ, therefore, increases in 
absolute weight, in circumference, and in the thickness 
of its walls (see Figs. 27, 28, 76), the greater part of the 
increase being added to the muscular layer. The latter 
fulfils i\NO functions during this period : the support of 
the ovum, which is embedded in the uterine mucosa, now 
transformed into the decidua, and draws sustenance from 
its abundant capillary and lacunar vascular system ; and 
the presentation of the mature fetus. In addition, the 
uterine muscle effects the expulsion of the ovum. The 
growth of the uterus is at first an active process, affecting 
both the length and the thickness of the muscle-fibers, 
and does not depend on the pressure of the developing 
ovum ; for the ovum is smaller than the uterine cavity 
during the first weeks of pregnancy, and the uterine 
enlargement takes place also in ecto2:)ic gestation. 



THE UTEBINE MUSCLE AND ITS FUSCTIONS. 63 

The size and shape of the uterus are determined by the 
extent of the muscular increase and tlie growtli of the 
individual fibers. This is seen most clearly in the first 
and second months, when the uterine cavity is larger than 
the ovum (Figs. 17, 18), showing that the uterus has an 
independent growth exceeding that of the ovum. The 
decidua refiexa and decidua vera do not begin to coalesce 
before the fourth month. 

The cervix in the virginal as w^ell as in the gravid 
uterus is poorly supplied with muscular fibers ; its func- 
tion is a passive one, at first to close the birth-canal and 
later to allow the ovum to escape. Even in the virgin 
state its chief difference lies in the structure of its mucous 
membrane, which is, in fact, incapable of producing a 
decidua. In rare cases the upper segment of the cervical 
canal undergoes exceptional development and assists in 
supporting the ovum, either owing to an intrinsic ten- 
dency to the formation of more robust muscular fibers 
and unusual elasticity of the uterine body, or because of 
a relaxed and softened state of the internal os, as, for 
instance, in inflammatory conditions (Bayer, Klistner, v. 
HerflP). This is almost always the case in primiparse 
toward the end of gestation. Its occurrence depends 
rather on accidental processes and functional variations 
than on a true hyperplasia of the tissue-elements. 

The muscularis of the cervix is composed of a relatively thin 
layer of obliquely circular fibers (Fio:. 65), traversed by numer- 
ous strands of connective tissue with some elastic fibers, the latter 
being most numerous at the external os. 

The muscularis of the body and fundus consists of two layers 
which can be traced into the tubes, the vagina, and the various 
ligaments, where they insert (like the outer layer) below the serous 
surface and radiate into the substance of the ligaments. The 
outer layer (Fig. 64) is composed of oblique longitudinal fibers 
which interlace as they pass from one half of the uterus to the 
other; some of the fibers run more deeply and merge with the 
in7ier layer. In postpartum contractions of the uterus the bundles 
composing this outer layer can be distinctly felt, and they can 
also be demonstrated in the prepared specimen. The muscularis 
of the fundus proper is formed by the inner layer; it consists of 
two robust masses of circular fibers on either side of the organ, 



64 NORMAL LABOR. 

Fig. 64. Superficial Layers of the Uterine Muscle (after Deville, from 

the atlas of Leuoir, See, aud Tarnier) : T, tube; P, ijortio vaginalis; 
Lg.L, broad ligament. 

Fig. 65. Deep Layers of the Uterine Muscle {Ibid.). 

Fig. 66. Arrangement of the Muscle-fibers (after C. Euge). 

Fig. 67, a and b. Decidua Vera Complete after expulsion (see ^ 12). 



the continuation partly of the inner circular and partly of the 
outer longitudinal iibers of the tubes. They are thus grouped 
about two central foci which correspond to the points of origin 
of the oviducts (Fig. 65). Evidences of the formation of the 
uterus by the union of Miiller's ducts are plainly recognized in 
this region. The inner layer is the first to develop. 

It is not always easy to distinguish these two layers. Formerly 
three layers were described ; the middle portion, being particularly 
well supplied with blood-vessels, was called the stratum vascuhsum 
(Fig. 14). 

In order to get a clear understanding of the function of the 
uterine muscle we divide the fibers into two groups : 

The principal fibers run lengthwise from the peritoneum to the 
mucous membrane, traversing the intermediate tissues of the 
uterine wall more or less obliquely and in a downward direction. 
These fibers are crossed by the connecting fibers which run vertically, 
the whole forming a succession of rhomboid masses covered as with 
roofing-tiles by the superincumbent outer layer (C. Ruge's "mus- 
cle-rhomboids," Fig. 66). The cross-fibers are derived from the 
round ligaments, the ovariopelvic folds, the broad ligaments, the 
sacro-, recto*, and vesico-uterine ligaments, and from the muscular 
fibers accompanying the blood-vessels. 

This irregular picture (Fig. 14) of muscle-fibers crossing each 
other in every direction is seen in the non-pregnant as w^ell as in 
the puerperal uterus. It is the result of the uterine contractions. 

The gravid uterus, on the other hand — except in the first few 
months — appears much distended in every direction and its walls 
are correspondingly tldn. This is because the non-contracting 
fibers are greatly increased in length ^ without being increased in 
number (Sanger). They are now all arranged in parallel longitu- 
dinal rows, separated by loose areolar connective tissue. Hence 
the softening first of the uterus and later of the cervix that is so 
distinctly felt. 

The longitudinal distention of the organ is due to the growth 
of the principal fibers, its increased circumference to that of the 
connecting fibers. 

In expanding peripherally the uterus mechanically displaces 
the loose connective tissue of the broad ligaments like an intra- 

1 The length is increased tenfold, the width fivefold. 



Tab. SO. 




THE VTEmyE MUSCLE AND ITS FUNCTIONS. 65 

ligamentary myoma, or an intraligamentary tubal pregnancy, or 
an ovarian cyst : it grows into the broad lujamt'iitH. The L^rowth is 
so great at the fundus as to push the adnexa and ligaments far 
down toward the cervix. The ligaments do not begin to tighten 
until the labor-pains come. on. At the beginning of pregnancy the 
volume of the uterus is to its weight as 1 : 14, toward the end, as 
6:1 (v. Herff). This is on account of the steady growth of the 
uterine tissues, which at last, however, diminishes. 

During the puerperiuni the muscle-fibers rapidly undergo a 
granular degeneration. Those nearest the mucosa (decidua) take 
on a characteristic zigzag shape (see Fig. 87); but they do not 
return to their original size. Other newly formed^ fibers are 
reduced to a minimum size, but remain as a reserve supply. This 
explains why the uterus after involution is completed is still 
larger than in the virgin state. • 

Diirincr pregnancy the uterus, like any other muscular 
organ, possesses a definite tone ; it is, however, not in a 
state of uniform contraction, but contracts at regular 
intervals with such force as almost to compress the 
organ to its utmost, especially during the latter half of 
pregnancy, although the contractions are sometimes ob- 
served from the beginning of the fourth month. These 
vigorous contractions make it impossible for the fettis to 
change its position or even to obey the laws of gravity, 
especially when labor is near at hand, for the fetal move- 
ments are in reality very weak, and only appear strong 
because the fetus is suspended in the amniotic fluid. 
Gravity can aifect only the pregnant uterus as a whole. 
The attitude of the fetus is determined neither by gravity 
alone nor by its own spontaneous or reflex movements, 
but by the contrcictions of the uterine muscle and the 
■" functional ovoid shape '* of the uterus. The head, being 
the most compact and at the same time most movable 
portion, is the part most readily acted upon ; the larger 
and firmer the head the more easily it is forced into tiie 
lower segment, against the internal os, where the muscular 
layer is least developed and there is, therefore, least ex- 
pulsive power. At the same time the rest of the body 
and the extremities, being coiled on themselves, are best 
accommodated in the broad, oval fundus uteri, which, 

5 



66 NORMAL LABOR. 

therefore, contains the trunk, breech, and extremities, while 
the head occupies the less muscular lower uterine seg- 
ment. Although the gravid uterus is soft and doughy, 
and, except during the frequent, imperceptible contractions, 
represents a flabby, yielding sac, yet the general effect of 
the regularly recurring contractions is to give it a distinct 
oyal shape and to cause the fetus to assume a correspond- 
ing attitude. As the contractions are not always uniform 
the palpating hand feels the contracting portions now as 
round, hard masses, now as ridges running lengthwise of 
the organ. 

Distinct ^' cephalic presentations^' are much more rare 
when either the fetus or the uterus is deformed (uterus uni- 
cornis or bicornis, partial inertia uteri), or the head is 
either abnormally small or enormously enlarged. 

The older the fetus and the larger and firmer the head 
the more frequent are cephalic presentations in premature 
births. 

Thus the long axis of the fetal trunk becomes exactly 
perpendicular to the plane of the inlet or coincides exactly 
with the long diameter of the uterus and a cephalic pre- 
i^entation results. In two-thirds of all cephalic presenta- 
tions the back is found on the left side of the mother and 
turns to the left and forward when labor-pains begin. 
This is called the fi7'st presentation (L. O. A.). It is due 
to the fact that the transverse diameter of the uterus, as 
explained above, usually coincides Nvith the right oblique 
diameter of the pelvis (B.), so that its left border is felt 
in front through the abdominal walls. Another reason is 
that the lordosis of the vertebral column in the later 
months of pregnancy prevents the fetal back from falling 
backward into the right half of the uterus. Until the 
onset of labor-pains the position of the back, whether 
anterior or posterior, is determined by gravity and possibly, 
to some extent, by the weight of the fetal liver ; but as 
soon as labor begins the back is rotated /orz6''«rc?. Another 
factor is the site of the placenta. 

In funnel-shaped pelves with lumbosacral kyphosis, 



THE UTERINE MUSCLE AND ITS FUNCTIONS. 67 

owing to the ab-ence of lordosis, the first and second pre- 
sentations (L. O. A and R. O. A.) occur with e(|ual fre- 
quency. It is said that among Japanese women the 
second ])resentation (R. O. A.) is more common than the 
first. If, as rarely happens, the uterus is displaced to the 
left there is every likelihood that the occiput has been 
rotated backward, or that by a simultaneous torsion on the 
other side a second cephalic presentation (R. O. A.) will 
result. 

LABOR-PAINS AND THEIR EFFECT ON THE FETUS. 

In contracting the uterus approaches, as far as the 
ovum permits, the pyriform shape of the virgin state : it 
becomes rigid, increases in length and depth, and meeting 
the resistance of the lumbar and sacral vertebrae forces 
the abdomincd walls forward. The body of the uterus, 
being a holloiv muscle, contracts ; the lower uterine seg- 
ment — owing to the absence of- muscular tissue or in 
obedience to antagonistic innervation — suffers longitudinal 
distention. The lower uterine segment, the cervix, and 
the vagina together constitute the outlet of the birth-canal. 
The cervix and the external os are poor in muscle-fibers, 
but rich in elastic fibers. The latter are arranged in two 
layers, an outer longitudinal and an inner circular (like 
the string of a tobacco-pouch), which is distended by the 
descent of the head, assisted by the contraction of the 
longitudinal or retraction fibers, which are anatomically 
and functionally connected w^ith the longitudinal fibers 
of the uterus and with the round ligaments. There is, 
in fact, a true sphincter, consisting not of muscular but 
of elastic fibers. The cervical canal and the lower uterine 
segment undergo during labor a dilatation equal to six 
times the natural diameter or about 3J in. (8 cm.). 

The contraction of the hollow muscle and the pressure 
of the abdominal walls, in combination with the resisting 
forces described, result in a general internal 2)ressure on 
the fetus. At first the uterus rises about a finger's breadth. 
The lower portion of the birth-canal, especially the 



68 NORMAL LABOR. 

"lower uterine segment," undergoes longitudinal disten- 
tion. This has the effect of stretching the fetus to the 
extent of about 1 J in. (3 J cm.), as has been proved by 
frozen sections ; pressure is exerted on the vertel)ral 
column of the fetus ('^ Fruchtwirbelsaulendruck^'). 

It appears to me that this theory of Lahs, while it takes due 
account of the important and undeniable phenomenon of the 
stretching of the fetus and the lengthening of the uterus during 
contraction, neglects thsit other force by which the uterus returns to its 
original fiat tened^ pyriform shape with slight anteflexion. This force 
is merely one of the components of the general internal pressure. 
It is tacitly included in the force which Schatz calls the "restitu- 
tion-force" ("Formrestitutionskraft") of the uterus.^ 

Litra-uterine pressure, registered in the plane of the inlet by 
means of a hollow rubber ball introduced into the cervix (after 
Schatz and Westermark), depends on : 

(1) The abdominal contractions and accidental intra-abdominal 
tension, such as gas, etc., forming together the intra-abdominal 
pressure ; 

(2) On the difference in level between the pelvic inlet and the highest 
point of the uterus (varies with the position of the body ; in the 
dorsal decubitus it is 30 mm. Hg.) ; and 

(3) On the tension of the uterine walls : volume of contents. 
Intra-uterine pressure diminishes after the membranes have 

ruptured ; it then tends to regain its former height, but is pre- 
vented from doing so by the discharge of the amniotic fluid and 
the descent of the fetus. The severity of the labor-pains is in 
direct proportion to the intra-uterine pressure. The curve at 
first rises very slowly, then there is a sudden jump, followed by 
a second gradual increase, till it reaches its maximum duration 
of 8.1 seconds. The fall is at first gradual, then more rapid, and 
finally very slow, until the ordinate is reached. 

Intra-uterine pressure varies between 20 and 220 mm. Hg. = 4 lb. 
6 J oz. and 55 lb. 2 oz. (2 and 25 kilos) ; the mean pressure = 55. Q— 
163.3, or 107 mm. Hg. (according to Schatz the maximum is 100 
=2202- lb. [10 kilos]). The labor-pains increase progressively, 
being greatest at the end of labor. According to Schatz's toko- 
dynamometer they have a strength of 18f to 6lh lb. (8.5 to 27.5 
kilos). They travel in peristaltic waves from the tube to the 
internal os. 

This peristaltic movement was observed by Kehrer in animals, 

^Schatz's theory differed from that of Lahs; he distinguished the 
"general uterine pressure," the "restitution-force" of the uterus and 
fetus, and, as a resultant of these two, the " pressure along the axis of 
the fetus " (" Fruchtachsendruck "). 



THE VTERINE MUSCLE AXD ITS FUNCTIOyS. 69 





CO c+S ri- n — ■i—iT' 



05 



03 O ET 5 5^ 3 



^. i< 



O 









o 
o 




l-l 

p 



70 



NORMAL LABOR. 




Fig. 5.— Eftective terminal bearing-down pain. 



Fig. 6.— Double pain, one a bearing-down pain, followed by an abortive 

pain. 




Fig. 7.— Intra- 
uterine pressure 
during bearing- 
down pains (after 
Schatz, for com- 
parison with the 
curves after au- 
thor's method, in 
Figs. 4-6, 8, and 
10). 



THE UTERINE MUSCLE AND ITS FUNCTIONS. 



71 



Last pain in dorsal 
decubitus with 
bearing down. 



c 

OD 



CI 

c 



cr 
cr 

o 



Head in vulva. rf; 

< — « Patient placed 1 

in side position. 2; 




Bearing down during 
interval. 



Labor-pain without 
bearing down. 

< — ^ Birth of head. 

Bearing down during 
interval. 

Last labor-pain. 
Birth of child 




72 NORMAL LABOR. 

and by v. HerfF in women during Cesarean sections. Ahlfeld, on 
the other hand, did not observe it. 

The author has studied the more delicate variations in the con- 
tracting uterus in the different periods of labor by means of a 
helmet-like contrivance applied to the fundus uteri, which, by 
means of a closed pneumatic apparatus and gasometers, trans- 
ferred the rise and fall during labor-pains and in the intervals 
between them to a drum.^ Toward the end of the first stage the 
pains increase in strength and duration, the intervals become 
shorter, and " complex " curves are more frequent (there are 
typical, simple labor-pains in the beginning of labor and more 
complete ones, double and multiple pains, and typical pains in 
groups). These curves are not influenced at all by rupture of the 
membranes, but undergo a decided change when the head begins to 
emerge from the fully dilated os. The maximum duration reached 
at tliis time remains unchanged throughout the second stage; but 
the apex of the curve rises still higher toward the end of this 
stage, the intervals become yet shorter, and the duration of the 
individual pains varies much more than during the first stage. 
The author's curves show a Mt, plateau-like apex (in harmony with 
older authors and Westermark, but contrary to Schatz) for the 
second stage of labor : 

Beginning of labor-pain, 0-50 seconds, average 15.8 seconds. 
Maximum duration, 14-75 " " 35.2 

Decline, 3-100 " " 32.9 

Westermark gives a maximum duration of 2 to 29 seconds 
(8.1 sec. on the average) ; it merely shows that the uterus requires 
a longer time to return to a position and shape of rest than the 
effect of the contraction on the internal pressure lasts. 

These investigations have a practical value for the estimation 
of atonic and partially tetanic labor-pains. 

The onset of labor, m other ^Yords, the duration of 
pregnancy, appears to depend on that regularly recurring 
cycle of rnetaboHsm, circulation, and innervation in which 
the sexual life of a woman finds its expression. 

Two hundred and eighty days, or ten lunar months, 
is tlie mean duration that is usually accepted, so that the 
tenth menstrual determination to the genitalia is the 
immediate cause of labor, which is, however, assisted by 
sundry external influences calling forth labor-pains. 

1 A few of the most instructive curves have been reproduced from a 
pamphlet published by Hirschwald, Berlin, 1896: " Activity of Labor- 
pains," etc, 



THE UTERINE MUSCLE AND ITS FUNCTIONS. 73 

DcUvery at term may occur between the thirty-eighth 
and forty-first week ; premature labor from tlie twenty- 
eighth to the thirty-eighth week (the child can be reared 
with proper care); miscarriage or premature labor from 
the sixteenth to the twenty-eighth week (the child is not 
viable, although the heart may continue to beat a few 
minutes or even hours ; the placenta serotina, as such, is 
completed in the beginning of the fourth month) ; abor- 
tioiij that is, the discharge of an ovum prior to the com- 
plete formation of the placenta, up to the sixteenth week. 
Pregnancy may be prolonged to three hundred days 
(partus serotinus after the forty-first week) ; in such cases 
the child is usually very large. Missed labor is the term 
applied to cases in which, labor having begun, the pains 
cease and the fetus is not expelled. 

It appears, then, that the onset of labor is regulated by a central 
mechanism. Among the co-operating factors, none of which in 
itself suffices to bring on labor, are: the overdistention of the 
uterus by the fully matured fetus ; tlie pressure exerted by the latter 
on the internal os ; the accumulation of products of fetal metab- 
olism, especially CO,, in the maternal tissues, due to a change in 
the course of the inferior vena cava of the child, which at the end 
of pregnancy empties into the right auricle, so that the head 
receives only venous blood ; and, finally, thrombosis in the placen- 
tal veins and necrobiosis of the decidua. The proximate exciting 
impulse to labor-pains is derived principally from the paracervical 
ganglia, although there is also a regulating center in the lumbar 
cord. 

Our knowledge of the nerve-supply of the sexual apparatus 
amounts to this: The uterus is innervated by three sets of nerves : 
ia) one set derived from the cord and passing through the sacral 
nerves (which cause the dolores conquassanfes when the head passes 
the vulva) to the lateral ganglia of the cervix in the posterior fornix ; 
[b) sympathetic fibers from the aortic, mesenteric, and hypogastric 
(on the promontory) plexuses, joining the uterine plexus on the 
aorta; (c) independent ganglia — Dembo's ganglia — in the anterior 
fornix (Fig. 68). 

All three sets contain both motor and sensory fibers, but the 
sacral nerves contain principally afferent inhibitory fibers. Pe- 
ripheral irritation of the ovarian nerves gives rise to marked 
uterine movements. 

Uterine contractions may be incited by sudden and great 



74 NOBMAL LABOR. 

Fig. 68. Nerve-supply of the Female Genitalia (modified from Frank- 
euhauser and Hirschfeld) : 1, inferior aortic hypogastric plexus ; 2, right 
inferior mesenteric plexus; 3, lumbar ganglion of sympathetic nerve; 
4, ovarian plexus (from renal and aortic plexuses), supplies tubes, ovaries, 
and fundus uteri; 5, third and fourth sacral nerves form the right infe- 
rior hypogastric plexus with the ganglionic systems 6 and 7, which 
supply the cervix; 8, uterine nerves; the lower part of the uterus is 
supplied by the inferior hypogastric plexus, the middle portion by the 
inferior aortic hypogastric plexus, the fundus by the ovarian plexus and 
filaments from the two last-named plexuses ; 9, vesical plexus ; 10, sciatic 
nerve; 11, branch of fourth sacral nerve to levator ani; 12, pudic nerve; 
13, its continuation as dorsal nerve of the clitoris ; R, rectum ; U, uterus ; 
B, bladder; D, transversus perinei muscle (in cross-section) ; 8, iliac bone; 
P, OS pubis; Ur, ureter; Ao, aorta; V, vagina; La, levator ani muscle; Ov, 
ovary ; T, tube. 

Fig. 69. Muscles of the Perineum (original drawing, modified from 
Savage, with corrections) : 1, gluteus maximus ; 2, levator ani ; 3, sphincter 
ani; 4, obturator externus ; 5, tubera ischii; 6, ischiocavernosus and erector 
clitoridis ; 7, constrictor vaginx ; 8, coccyx; 9, symphysis and suspensory 
ligament of the clitoris; 10, gland of Bartholin ; 11, anus ; 12, vagina; 
13, urethra; 14, the connective tissue and fascia shown in Fig. 30, 6, 7; 
15, great sacrosciatic ligament. 

loss of blood, by an excess of CO^ in the general circula- 
tion, by high, febrile temperatures, by quinine, sodium 
salicylate, ergot, and other poisons (strychnine), and by 
experimental irritation of the ovarian nerves belonging to 
the ovarian plexus (formed by branches of the renal and 
aortic plexuses) and functionally connected with the 
uterus and uterine plexus by means of the two ovarian 
ganglia. The entire sympathetic system of the genital 
organs can be traced back to the celiac ganglion, Avhich, 
as is well known, contains fibers from the vagi. Lastly, 
labor-pains may be excited by direct irritation of the uterus; 
this acts reflexly, hence the resulting pain induces the 
contractions which follow ; on the other hand, uterine con- 
tractions may also be induced by independent centers in 
the uterus, without the intervention of the central nervous 
system (Fig. 68). There is also a reflex communication 
between the mammae and the uterus. 

The uterine nerves are most irritable at the end and 
at the very beginning of pregnancy ; during the entire 



THE FIRST OR DTLATATION STAG?: OF LABOR. Ir) 

period they are thickened by an overgrowth of connective 
tissue. It has been experimentally proven that conception 
and parturition are })ossil)le after complete destruction of 
the lumbar cord. This has even been observed in women 
after all connection with the higher portions of the cord 
and the cerebrum had been severed, as in paraplegia, 
echinococcus, neoplasm on a thoracic vertebra, etc. The 
innervation is probably derived from Dembo's centers. 
The uterus itself contains no ganglia, but numerous cellu- 
lar elements of various shapes are found embedded in a 
network of sympathetic fibers anastomosing with them 
and with each other. In addition to and separate from 
these there are long medullated cerebrospinal fibers run- 
ning through the uterine substance. 

The sensory nerves of the vagina and vulva also par- 
ticipate in the act of parturition, as in other generative 
processes, by virtue of their influence on labor-pains and 
on the musculature of the vagina. These parts are sup- 
plied by the pudic nerve and its branch to the clitoris ; 
irritation of them is follow^ed by engorgement of the 
vessels of the cervix, vagina, and vulva (through the 
inferior hypogastric plexus), and by contraction of the 
constrictor vagince, levator ani, and all the muscles that 
enter into the formation of the pelvic floor (through the 
sacral nerves), and play such an important role during the 
passage of the presenting part. 

§ 6. THE FIRST OR DILATATION STAGE OF LABOR. 
BEHAVIOR OF THE LOWER UTERINE SEGMENT AND 
OF THE CERVIX DURING THIS PERIOD. 

As a rule, the cervix takes no part in the support of 
the ovum during pregnancy ; at most some decidual cells 
may be found a few millimeters below the internal os, 
hence the l)ody of the uterus proper only is adapted to 
the reception of the ovum. The entire cervix remains 
unaltered until the onset of labor, the shortening of the 
vaginal jortion being the only apparent change, as shown 
in § 2. In the cases in which, owing to slight dilatation 



76 NORMAL LABOR. 

of the (anatomical) internal os, the portion immediately 
l)elow it becomes the seat of deciclua-formation, the boun- 
dary of the cervical mucosa is marked by a slight thick- 
ening, known as Muller's ring. In primiparse, however, 
the internal os and the upper portion of the cervical canal 
do, toward the end of pregnancy, participate in the dilata- 
tion of the lower uterine segment. 

With the onset of labor-pains the muscularis of the 
body of the uterus contracts over the child in a direction 
toward the fundus, so that a propulsive force is exerted 
along the longitudinal axis of the child toward the true 
pelvis, except in transverse presentations. But, since the 
child is propelled forward, the uterine muscle must find a 
point cVappid in the maternal body as soon as the present- 
ing part meets with resistance, as at the brim, at the rectum 
distended with feces or at a distended bladder, at the 
iliacus and psoas muscles, at the surfaces of the acetabula, 
at the spines of the ischium, at the levatores ani and con- 
strictor vaginae, at the coccyx, at the perineum, and at 
the symphysis. 

When the uterus is forcibly contracted to overcome 
abnormal resistance, such as that offered by a contracted 
pelvis for instance, this line of fixation must coincide with 
the lower boundary of that portion of the genital tube 
which suffers the greatest longitudinal distention when 
the contracting force of the fundus is exerted ; [that is to 
say, the lower uterine segment, as will appear in the next 
paragraph. — Trans.] 

The recently evacuated uterus ^ of a woman who has 
died during childbirth ])resents two distinct divisions: the 
contracting uterine body with thick walls, and a thinner 
portion extending to the external os. The pregnant con- 
tracting uterus, before dilatation of the internal os^ has 
occurred, presents three more or less distinct zones : the 
contracted upper part of the body ; a distended lower 

^ Bvaune's frozen section of a parturient woman {Y\^. 4, in Ailas of 
Obstetrics, I., niodified) in the second stage of labor; Schroder's speci' 
men of a woman just delivered (1886 . 

2 Schroder-Stratz (1886), frozen section. 



THE FIRST OR DILATATION STAGE OF LABOR. 77 

portion, the so-callod " lower uterine segment," about 2|- 
in. (7 cm.) in leno'th, extending to the internal os ; and 
the intact cervical canal. The lower boundary of the 
contracting zone of the fundus is marked by a ridge of 
thickening, the '' contraction-ring," which, however, can 
rarely be distinctly recognized as a persistent element even 
in the living subject, and practically never in the cadaver. 
It follows that the entire genital canal below the contrac- 
tion-ring undergoes lateral distention during labor, wliile 
true longitudinal distention can take place only in the 
above-mentioned region, extending from the internal os 
to the contraction-ring ; this part of the uterine body is, 
therefore, the true '• lower uterine segment." It is stretched 
by traction, while the cervical canal and vagina, with 
ordinary or slightly increased resistance, represent the 
dilated portion of the birth-canal, that part which is sim- 
ply thinned by the pressure on its walls from within. 
But under abnormal conditions of resistance this latter 
portion may partially assume the character of a distended 
segment; in other words, in forced contractions the genital 
canal seeks a deeper point of fixation. The first or upper 
point of fixation is found, as we have shown, in the region 
about the internal os ; the manner of its attachment will 
be studied later. What, then, is the second more deeply 
situated point of fixation ? 

Among the many specimens of rupture of the uterus 
in the Munich Gynecological Clinic the line of rupture in 
most cases was longitudinal or oblique, or in the form of 
a transverse tear with a long triangular flap pointing 
downward, beginning above at the contraction-ring and 
ending below at a point 4- to 4- in. (0.5 to 2 cm.) above 
the external os (see Fig. 16 in the text). In some of the 
specimens the tear is continued directly into the vagina, 
but more frequently it ends at the above-mentioned point 
in the cervical canal, leaves the os intact, and is then con- 
tinued into the vaginal vault. It is evident, therefore, 
that there are three 'Hower points of fixation": (a) at the 
level of the cervix, i. e., at the internal os, under normal 



78 NORMAL LABOR. 

conditions; (b) about ^ to |- in. (0.5 to 2 cm.) above the 
internal os (in puerperal specimens) when the pressure is 
abnormally increased ; (c) in the vaginal vault. 

These phenomena find a, partial explanation in the anatomical 
structure of the parts. In [a) fixation is effected by the muscular 
fibers and thick, tendinous bundles of connective tissue, which are 
found partly in the retro-uterine peritoneal folds of Douglas and 
partly in the lower, basal portions of the broad ligaments, from the 
level of the internal os downward as far as the fornix, enclosing 
the genital canal and fixing it to the pelvic wall. These glisten- 
ing, tendinous bands of connective tissue constitute what is 
known as the llgamentum cardinale (Kock), and merge into the 
sacrorecto-uterine and pubovesico-uterine ligaments and the tis- 
sues forming the lateral walls of the pelvis (see Fig. 75). 

Above the cross formed by these ligamentary bands the uterus 
is loosely attached to the adjoining organs by areolar tissue, such 
as is found under a serous surface ; it lies beneath that part of 
the serous membrane which lines the vesico-uterine and recto- 
uterine fossae in front of and behind the uterus, the lateral por- 
tions forming part of the broad ligaments. The latter represent 
the mesentery of the internal sexual organs; during pregnancy 
their bulk is much increased by the hyperemia of the vascular 
system. In the same way the peritoneum increases in thickness 
and extent in all parts of the genital tract, both by virtue of its 
elasticity and power of adapting itself to the uterus and by 
actual cell-proliferation. The peritoneum extends from the 
bladder to the internal os or a little higher, forming the excava- 
tion bounded by the vesico-uterine folds. Below the peritoneum 
the connection between the uterus and bladder is maintained by 
loose connective tissue. 

The body of the uterus is, therefore, covered by peritoneum, 
forming the closely adherent " perimetrium," which is continued 
to the pelvic walls on each side as the broad ligament. The 
upper border lodges the oviduct, covered by a duplicature of the 
membrane which is continued to the linea terminalis as the sus- 
pensory ligament of the ovary (infundibulopelvic ligament). 
The ovary and parovarium occupy the posterior surface of the 
broad ligament, but are not completely enclosed by it. The loose 
connective tissue and the blood-vessels are found between the two 
serous layers. The infundibulopelvic ligament arches backw^ard 
to the brim of the pelvis, where it is inserted above the bifurca- 
tion of the common iliac artery. From this point the broad 
ligament sweeps forward and backward and descends with the 
hypogastric artery. 

In close relation with the hypogastric arteries are found the 
ureters, which describe a curve with its convexity outward and 



THE FIRST OR DILATATION STAGE OF LABOR. 79 

backward, and descend obliquely from without inward and from 
behind forward to the base of the broad ligament. The left 
ureter is near the median line, but the right is nearer the internal 
OS (f in. = 19 mm.), on account of the dextroposition of the uterus 
from the pressure of the rectum; it is only | in. (8 mm.) from 
the supravaginal portion of the cervix and \ in. (6 mm.) from 
the vaginal vault. At a point -^ in. (15 mm.) lower down the 
ureters are found on the anterolateral wall of the vagina, which 
they cross at an acute angle. 

The peritoneum leaves the posterior surface of the uterus at 
about the level of the internal os, after forming at this point a 
thickened ridge (Figs. 29, 32), which contains numerous muscle- 
fibers and is continued into the sacro-uterine and recto-uterine 
folds of Douglas. These fibers form the so-called reiradores uteri 
of Luschka. Immediately below is the attachment of the above- 
described intersecting ligaments, the lateral portions of which 
also contain smooth muscle-fibers. 

The peritoneum dips down f to 4 in. (1 to 2 cm.) below Douglas' 
folds into the recto-uterine or Douglas' pouch, as far as the pos- 
terior ibrnix (hence lower than in front), and from this point is 
reflected back over the rectum and to the posterior pelvic wall. 

Beneath the peritoneum of the broad ligament the round liga- 
ment forms a distinct ridge, which passes on either side from the 
junction of the tube downward, forward, and outward through 
the inguinal canal. Here it receives a tubular extension of 
peritoneum, the canal of Nuck {processus vaginalis per itonealis). 
Emerging from the external abdominal ring it passes to the mons 
veneris, where it receives striated muscle-fibers from the internal 
oblique. The uterine extremity contains smooth muscle-fibers. 
During pregnancy the round ligament enlarges to the thickness 
of a finger, partly from increase of the muscular portions. As 
the uterus rises above the inlet the course of the round ligaments 
and of the oviducts approaches the perpendicular, although the 
fundus still arches over far above them. During parturition the 
ligaments are stretched and the left one is easily palpated, as the 
uterus rotates into the right diagonal. 

From the foregoing description it follows that the space 
on either side of the uterus, as far down as the internal 
OS, contains only a loose, non-resistant connective tissue, 
while below the internal os, as far as the fornix, is 
attached the more resistant lie/amentum cardinale^ con- 
taining muscular fibers and forming the first point of fixa- 
tion mentioned under (a), in the longitudinal extension of 
the lower uterine segment. 



80 NORMAL LABOR. 

At the second j^oint of fixation (b), 3- to f in. (^ to 2 cm.) 
above the external os in the cervix, the tension increases 
until the bridge of tissue connecting the vault of the 
vagina with the nearest point of the cervix is stretched to 
the utmost ; the resistance is then supplied by the walls 
of the fornix, which are fixed by the closely adherent 
peritoneal fold at the deepest part of Douglas' pouch 
(Figs. 17, 18, 27). Hence, if the uterus ruptures, the 
tear either extends to the above-mentioned point in the 
cervix nearest the fornix, -|- to |- in. (^ to 2 cm.) above the 
external os, or it passes from this point directly into the 
vault of the vagina (the external os may or may not 
escape), since the latter, like the cervix, is quite firmly 
supported by tendinous bands of connective tissue extend- 
ing in all directions, especially to the sacrum ; the vault 
of the vagina then corresponds to the third jjoint of fixa- 
tion which we have designated (c). 

But neither the fact that the cervix and vagina have a 
common mode of fixation nor their close anatomical rela- 
tion suffices to explain why these two structures are 
usually torn to the exclusion of the external os ; a third 
and very important reason is that both are subject to the 
same muscular pull, since the greater part of the cervical 
fibers pass directh/ over the fornix and blend rvith the 
lonr/itudinal fibers of the vagina. 

Lastly, tlie position and direction of the tear de])end on 
the position of the presenting part, over which the 
attenuated uterine wall is stretched.' By the counter- 
pressure of a second force the original simple traction is 
converted by leverage into a more powerful resultant. 

There are several reasons why it is a priori doubtful 
whether fixation takes place at any deeper points^ when 
the head forcibly engages in the superior strait. In the 

1 Among 100 cases of total rupture of the uterus with complete escape 
of the child, I found 43 anterior, 17 posterior, 11 lateral. The remainder 
were due to violence, old Cesarean scars, myoma-insertions, etc. 

2 Such fixationis afforded hy the constrictor va^inse and levator ani 
muscles, which serve to prevent total prolapse in the hijihest degree of 
inversion of the uterus with inversion of the vagina (see Fig. 30). 



THE FIRST OR DILATATION STAGE OF LABOR. 81 

first place the advancing head wedges the walls of the 
parturient canal fast at the inlet (thus, the fold in front of 
the head seen in Braune's frozen section of a parturient 
woman is, I think, due to the relaxation of the previously 
contracted tissues, cf. PL 49) ; then the vagina, following the 
line of the parturient canal, is concave forward, and this 
curve would first have to be reduced before the structure 
could take part in the longitudinal distention ; and finally, 
after the largest diameter of the head has passed the inlet, 
the presenting portion is only at the level of the spines of 
the ischium, that is to say, the greater part of it is still 
within the cervical canal, above the point (^c), which marks 
the fixation-point of the vagina. As a matter of fact 
such lacerations of the vagina never occur as a result of 
excessive longitudinal distention, even when the resistance 
is situated lower than the inlet. Thus, in funnel-shaped 
pelves, where the contraction is situated at the outlet, 
vaginal tears occur only from circumscribed pressure- 
necrosis or from violence. 

The '' lower uterine segment " then exists as such as 
early as the first half of ])regnancy. According to some 
authors (Hofmeier, von Franque, Ruge, Veit) it exists as 
an anatomical structure even in the virgin state, the 
above-mentioned authors basing their belief on the rela- 
tion of the anterior peritoneal attachment and of the 
uterine vessels to the contraction-ring. There is an active 
growth in this region during pregnancy. The internal os 
must be regarded as the lower boundary of the " lower 
uterine segment ''; this view, it seems to me, finds further 
support in the fact that decidua formation ceases at this 
point ; in the fact that the internal os remains closed 
until the onset of labor ; and especially in the fact that 
on this assumption the inferior fixation of the uterus in 
an obstetrical sense takes place at this point. The con- 
traction-ring which forms the upper boundary must also 
be considered an anatomical part of the body of the 
uterus, but its shape and significance are brought out 
only by the contraction of the muscularis of the fundus 

6 



82 NORMAL LABOR. 

and body ; it is conspicuous in direct proportion to the 
number of muscle-fibers in the uterine walls above the 
internal os and the strength of the contractions. The 
cervix contains few muscle-fibers and, therefore, does not 
contract ; on the other hand, it suffers little or no elonga- 
tion during pregnancy, and the increase in thickness is due 
more to edematous swelling and relaxation of the tissues 
than to an increase in the muscle-fibers. It follows that 
the upper limit of the ''lower uterine segment^' depends 
on the function of the muscularis, and we should expect 
to find it in this structure at the point where the muscle- 
fibers, in respect to number and arrangement, begin to 
assume the character of the muscularis at the fundus. 
This zone coincides approximately with the line of attach- 
ment of the anterior perimetrium and the entrance of the 
uterine artery. This definition will be found in the 1894 
edition of this Atlas ; v. HerflP adopted the same view in 
1897 ; and v. Dittel in 1898 was forced to the same con- 
clusion by his histological investigations. It is for this 
reason that the contraction-ring, representing as it does a 
function which ceases with life, is so rarely seen in the 
cadaver. When v. Herff found it in a Cesarean section 
he described it as a " contraction-phenomenon,'^ which, as 
such, is of the greatest practical significance. 

So far we have considered only the anatomical charac- 
ters of the parturient canal. In regard to the fetus and 
the part it plays in the process we now know the fol- 
lowing facts : (1) The trunk suffers extension during the 
uterine contractions ; (2) it presents a jwint (Fappui to 
the fundus which rises above it as it contracts ; (3) the 
advancing head, even before the onset of labor, follows 
the line of least muscular resistance and is pushed into 
the " lower uterine segment.'^ 

During the dilatation stage the head burrows down 
into the anterior wall of the lower uterine segment, 
which it pushes before it into the vault of the vagina. 
A part of its advancing segment is, therefore, deeper 
than the internal or even the external os. In a normal 



THE FIRST OR DILATATION STAGE OF LABOR. 83 

birth the bag of waters is still intact at this stage, and as 
it is forced into the cervical canal dilates the latter com- 
pletely. But if the membranes are ruptured prematurely, 
the dilatation of the cervix must be effected by the hard, 
unresisting head, and is accordingly more painful; be- 
sides, the head becomes much more firmly fixed by ad- 
hesion in the anterior, bulging portion of the ^' lower 
uterine segment." This may give rise to disturbances of 
the circulation, edematous swelling of the tissues about 
the OS, and partial contraction-spasms. The dilatation 
of the cervix is heralded during the latter part of preg- 
nancy by a softening of the walls progressing from above 
downward. 

If the inlet is contracted, the muscularis of the 
fundus, on the one hand, is unable to force the head 
into the inlet, and the cervix, on the other hand, being 
wedged in and held fast by the head, cannot respond to 
the upward pull of the uterine muscle. In such cases 
the above-described tendinous ligaments, which sur- 
round the cervix and vagina, do not come into action at 
all, the lower uterine segment is held fast by the head 
itself and is stretched upward ; it gives way at the point 
where the tension is greatest, i. e., opposite the vault of 
the cranium. 

To sum up the function of the ^Mower uterine seg- 
ment," it forms that part of the uterus which receives the 
presenting part (head) of the fetus and allows it to de- 
scend at the onset of labor. The effect of this is that 
the cervical canal is at the same time directly dilated by 
the advancing membranes, or, if the latter have ruptured 
prematurely, indirectly by the pull of the uterine walls 
and the pressure of the head on the anterior, bulging 
portion of the ^^ lower uterine segment." The latter can 
perform its office only wdien its contractile power, or in 
other words, its muscular development, is much less than 
that of the fundus. Hence, it begins where the muscu- 
laris of the fundus ends ; when the organ is firmly con- 
tracted the thickness of the walls diminishes abruptly, 



84 NORMAL LABOR. 

Fig. 70. Tlie Pelvic Inlet ; its Diameters and their Average Normal 
Lengths, and its Musculature (70-72, modified after Veit) : 1, body of 
the first sacral vertebra ; 2, symphysis ; 5, obturator foramen ; 6, head 
of the femur ; 7, iliac bone ; 8, iliacus muscle. 

Fig. 71. The "Principal Plane" of Veit, through the Lower Border 
of the Symphysis, Parallel with the Plane of the Inlet : 1, the second 
and third sacral vertebrae; 3, iliopsoas muscle; 4, obturator internus 
muscle ; 5, obturator fascia ; other numbers as in the preceding figure. 

Fig. 72. Plane of Pelvic Expansion : 4, obturator internus muscle ; 
9, pyriformis muscle. The cross indicates the point of intersection of 
the conjugate with the transverse diameter, which is situated much 
farther forward than the larger transverse diameter of the inlet; the 
latter plane was oval and oblique, this one is oval and horizontal. 

forming the " contraction-ring." Hence, a tear occurring 
in excessive contraction of the uterus, when there is 
undue resistance, such as is offered by a contracted inlet, 
begins at the contraction-ring and extends through the 
^^ lower uterine segment," where the tension is greatest, 
as far as the internal os. 

The first or dilatation stage ends with the complete 
dilatation of the external os, allowing the head to pass. 
A distention of about 4 in. (10 cm.), or the size of the 
palm, suffices for this purpose. The process is least pain- 
ful when effected by the membranes. Labor begins with 
the regularly recurring contractions of the uterus, known 
as labor-pains, by which the uterus alternately hardens 
and relaxes, and with the protrusion of the bag of waters 
into the cervical canal. The latter consists principally of 
elastic connective tissue, the resistance of which in the 
process of dilatation is overcome partly by the pressure 
of the bag of waters and partly by the contraction 
of the longitudinal fibers of the uterus and of the 
vaginal fibers which extend into the ])ortio vaginalis. 
Since the external os lies in the interspinal line, it can be 
completely dilated and receive the head only when the 
largest diameter of the latter has reached the plane of 
expansion, that is to say, has passed the inlet. The bony 
pelvis now begins to exert a marked influence on the 
movements of the liead. 



Tab. 32. 




Fig 72. 



LUh.Anst !■: ReidiJioLd, Mimchen. 



THE SECOND OR EXPULSIVE STAGE OF LABOR. 85 

g 7. THE SECOND STAGE (STAGE OF EXPULSION) AND 
THE RESISTANCE OFFERED BY THE PELVIC 
PLANES AND THE FLOOR OF THE PELVIS. 

"We saw in s3 that the largest diameters in each of the 
pelvic planes do not run in the same direction. At the 
inlet the transverse diameter is the largest ; when the 
head, therefore, engages in the true pelvis its greatest 
diameter, the occipitofrontal, coincides with the trans- 
verse diameter of the brim ; the sagittal suture is felt in 
the transverse diameter and, since the latter lies nearer 
the sacrum (see Fig. 70), the sagittal suture in at least 
one-third of the cases is found to be nearer the promon- 
tory. This is known as NdgeJe's obliquity, or presenta- 
tion of the anterior parietal bone. If the advancing 
part is not oval like the vertex, but more spherical like 
the face or the breech, the longest diameter is forced away 
from the promontory and coincides with the oblique 
diameter of the inlet ; the same thing occurs in vertex 
presentations (Solayres ohliquity) in rare cases with com- 
plications. The size of the inlet is further diminished by 
the iliopsoas muscles, in addition to the pelvic viscera, 
and the greatest transverse diameter is thereby displaced 
slightly forward toward the symphysis. These muscles 
can be relaxed bv flexing and supporting the legs (Figs. 
60, 61, 70). 

The second plane is the plane of pelvic expansion, 
passing through the middle of the third sacral vertebra 
and the middle of the symphysis ; the oblique is its 
largest diameter, hence the sagittal suture rotates into it ; 
the lesser fontanel can usually be felt at the anterior ex- 
tremity of the oblique diameter. This is the second rota- 
tion of the head ; the Jirst rotation occurs when the 
smallest or suboccipitobregmatic circumference of the 
head descends into the funnel-shaped pelvis, and is effected 
by flexion of the head on the chest, assisted by the uni- 
form contraction of the uterus and the tilting due to the 
pressure of the vertebral column on the condyles. The 
oblique diameter of the plane of pelvic expansion is con- 



S6 NORMAL LABOR. 

Fig. 73. Skull of a CMld at Term (side view ; from an original photo- 
graph) : r.-Fr.o., straight or froiito-occipital diameter, corresponding to 
the fronto-occipital distance or circumference; o.mj. and o'.mj., major 
oblique diameter, according as the most distant posterior extremity cor- 
responds exactly with the lesser fontanel or lies above it; G.L., the 
largest circumference of the head that has to pass in face presentations 
(the anterior extremity is the larynx) ; o.mi.-s.o.br., minor oblique 
diameter, corresponds to the suboccipitobregmatic distance and circum- 
ference ; H.L., the largest circumference that passes in occipital presen- 
tations, does not quite correspond to the suboccipitobregmatic circum- 
ference ; F.Si.i and V.St.,'^ the two largest circumferences that pass in 
brow presentations, according to the method of delivery. The frontal, 
lambdoid, and temporal sutures and the two temporal fontanels are seen. 

Fig. 74. The Same, Seen from Above (from an original photograph) : 
tr.mj., major transverse or biparietal diameter ; tr.mi., minor transverse 
or bitemporal diameter. The greater or anterior fontanel ; quadri- 
lateral, formed by four sutures: the frontal, the two coronary, and the 
sagittal, which leads to the lesser, triangular or posterior fontanel, and 
joins the lambdoid sutures. The radiating structure of the parietal and 
frontal bones and their junction with the parietal and frontal eminences, 
also the junction of the occipital bone (squama occipitis) with the occipital 
protuberance, are important from an obstetrical point of view. 

siderably shortened by the pyriform and obturator intern ns 
muscles, but is nevertheless elastic, as the posterior 
boundary is not formed by bone and the anterior is partly 
supplied by the obturator membrane (Fig. 72). 

There is a certain developmental relationship between the size 
of the fetal skull and the maternal pelvis. The size of any indi- 
vidual skull is, of course, influenced by certain hereditary factors 
derived from parents and grandparents, and particularly by con- 
ditions influencing the mother during pregnancy and the father 
at the time of impregnation (diseases, nutrition, etc.). The nutri- 
tion of the child bears a direct relation to the size and hardness 
of the bones of the skull and the smallness of the fontanels, and 
hence, also, to the body weight and the size and hardness of the 
head. A certain relationship also exists between the weight of 
the child and the weight and age of the mother. According to 
the author's statistics mothers between the ages of twenty and 
twenty-nine years of age and weighing over 121 lb. (55 kgm.), 
especially multiparse, produce relatively the heaviest children, 
and by far the greater number of them are boys. The head of a 
child at term is about six-tenths the size of the mother's in all 
its dimensions, but it is not a miniature of the mother's head. 



Tab. 33. 




Fig. 73 




Fig. 74. 



Liih.Anst E Reichhold, Miincheri. 



THE SECOND OR EXPULSIVE STAGE OF LABOR. 87 

In multiparte the later children have larger (l to -^ in. = ^ to | 
cm. ill every diameter) and firmer heads than the earlier ones. 

The skull of an infant at term has the following average dimen- 
sions: 

Suboccipitohregmatic circumference, 12f in. (32 cm.) (passes in 
the ordinary occipital presentations). 

Fronto-occipltal circumference, 13| in. (34 cm.) (passes in occip- 
ital and brow presentations). 

Mcntofrontal circumference, 12f in. (32 cm.) (passes fiirst in face 
presentations). 

Submento-occipital circumference, 14f in. (36f cm.) (passes last in 
face presentations). 

Fronto-occipital diameter, 4f in. (12 cm.) (glabella to external 
occipital protuberance). 

Biparieta I {major transverse) diameier, S^ in. (9i cm.) (between 
the two parietal eminences). 

Bitemporal (minor transverse) diameter, S^ in. (8 cm.) (between 
the two temporal fontanels). 

Mento-occipntal (major oblique) diameter, 5f in. (13J cm.) (from 
the chin to the farthest point on the occiput). 

Suboccipitobregniatie (minor oblique) diameter, 3| in. (9^ cm.) 
(from the nape of the neck to the greater fontanel). 

Vertical diameter, 3f in. (9J cm.) (from the vertex to the foramen 
magnum). 

During intra-uterine life the fetal skull increases in w^idth and 
the non-ossified portions — sutures and fontanels — diminish. As 
early as the fifth month the right parietal bone is flatter than the 
left. This phenomenon depends on a physiological difference in 
the growth of the entire right half of the brain, as the author 
has found foss?e and hemispheres on the left side larger than on 
the right as early as the fifth month. This observation is an in- 
teresting addition to the chapter on "right-handedness." It is 
also interesting to note that in the first or commonest vertex pre- 
sentation (L. O. A.) the flattened right side of the skull exactly 
fits the outline of the pelvic inlet, which is normally somewhat 
flattened on the right side. As the left half of the pelvis is usu- 
ally somewhat larger than the right, that is, the first or right 
oblique diameter is the larger, so the first vertex presentation 
(L. O. A.) is the most common. Whenever the oblique diameters 
were perfectly symmetrical, the pelvis was found to be unusually 
small; w^hen, on the contrary, the left oblique diagonal was the 
larger, the pelvis was unusually large, especially in the anterior 
transverse diameter (iliopubic distance). The second vertex pre- 
sentation (back on the right side, lesser fontanel in front and to 
the right, R. O. A.), it is true, is more common when the left 
oblique diameter is the larger, but, as the entire pelvis is larger, 
this relation is not so constant as the contrary one. 



88 NORMAL LABOR. 

The skull adapts itself to the shape of the pelvic canal 
during labor by the movements of its bones on each other. 
It is most important to bear this in mind. The greatest 
changes take place in the transverse diameters, which are 
diminished by twice the width of the sagittal, frontal, and 
coronary sutures ; these sutures are several millimeters 
wide. 

The compression takes place in such a way that the 
edges of the right parietal bone, which (in the first vertex 
presentation, L. O. A.) is the deepest and most anterior 
part of the head, overlap all the others, while the left frontal 
bone, which is the most posterior part (toward the sacrum), 
is depressed, that is to say, overlapped by all the adjoin- 
ing bones. The left parietal and right frontal bones 
occupy an intermediate position between these two. The 
fontanels also play an important role in the compression 
of the head. The total diminution iiT size amounts to 
from I to f in. (IJ to 2 cm.), especially if the flexibility 
of the parietal bones is taken into account. The posterior 
frontal bone becomes slightly flattened by the pressure 
of the promontory. As the transverse diameters are di- 
minished there is a corresponding elongation in the sagittal 
direction, and here again there is a difl^erence in the two 
sides. Corresponding to the greater curve of the right 
iliopectineal line the anterior right parietal bone, in the 
first vertex presentation (L. O. A), bulges more outward, 
while the left, which is nearer the sacrum, is pushed forward 
toward the frontal bone. Hence the movement of the 
two halves of the skull on each other is asymmetrical : the 
right half moving more backward, and tiie left forward. 

The part which is the most advanced during labor is 
drawn out to a point and forms the ajiex of a cone, the 
base of which corresponds to that plane which passes first 
(cf. the explanation of Fig. 73) ; thus, in the first vertex 
presentation (L. O. A.), the suboccipitobregmatic circum- 
ference forms the base of a cone, the apex of which is the 
angle of the right parietal bone, which is in contact with 
the occipital bone and the sagittal suture. This explains 



THE SECOND OR EXPULSIVE STAGE OF LABOR. 89 

the situation of the caput succedaneum and of cephal- 
hematoma, which are caused by tlie pericranium, together 
with the skin, adhering to the maternal soft parts and 
becoming se})arated from the skull during the intervals 
between labor-pains (Fritsch). 

The distortions of the head during labor in vertex 
presentations consist not so much in measurable changes 
in the length of the head, as in a flattening of the region 
about the brow and anterior fontanel, an arching of the 
presenting parietal bone, and, in protracted labors, a more 
vertical position of the squamous portion of the occipital 
bone. 

According to the author's observations these deformities disap- 
pear after twelve or, at most, twenty-four hours. If the deformity 
was more serious, three to four days were required. In the case 
of presentation of the occipital bone it appears probable that the 
deformity may persist for several weeks, and even in a modified 
form throughout the individual's life. In face, brow, and even in 
anterior fontanel presentations, the deformity is unquestionably 
permanent if there is marked contraction of the birth-canal. The 
condition can be determined only by making a cast of the head ; 
measurements are unreliable. 

In our discussion of the influence exerted by the differ- 
ent pelvic planes on the advancing head we had reached 
the plane of pelvic expansion. As a matter of fact, the 
widest part of the pelvis is VeW s principal plane (Fig. 71), 
which passes through the lower border of the symphysis, 
parallel to the inlet. It forms a broad, almost circular 
oval, being but little encroached upon laterally by the 
iliacus and psoas muscles. The anterior boundary is very 
yielding, being formed by the broadest part of the obtu- 
rator membrane and a thin layer of the obturator internus 
muscle. At this point the head, which is now entirely 
within the cervical canal, the os being fully dilated (3J to 
4 in. = 8 to 10 cm.), begins to rotate so that the sagittal 
suture coincides with the oblique diameter, Avhile at the 
same time the presenting part of the cranium (after the 
membranes have ruptured) begins to dilate first the mus- 
cular tissues of the vagina and then the pelvic floor. The 



90 NORMAL LABOR. 

head now comes in relation with the pubic arch, which is 
the least resistant portion of the birth-canal and plays 
such an important role in the second rotation of the head 
and the passage of the vertical diameter. The head is 
guided toward it by the resistance offered to the advancing 
parietal bone by the levatores ani muscles and the tissues 
forming the pelvic floor (Fritsch). From above down- 
ward the transverse diameters of the pelvis progressively 
diminish, while the anteroposterior diameters increase. 

After the os is completely dilated the bag of waters 
usually ruptures immediately and the head advances with 
its largest diameter into the dilated os, occupying the inter- 
spinal line or pelvic strait of greatest pelvic contraction 
(Fig. 72). _ 

The significance of this plane of the pelvis rests on the 
following considerations : 1. Its conjugate, which measures 
4| in. (11^ cm.), is much less extensible than is that of 
the outlet, which increases from 4 to 4|^ in. (10 to 12 cm.), 
owing to the mobility of the coccyx. 2. It contains abso- 
lutely the shortest diameter of the entire pelvis, the 
interspinal line. 3. The external os and the advancing 
segment of the head can be palpated in this plane as soon 
as the largest diameter of the head has entered the true 
pelvis and the external os is dilated to from 2 to 3^ in. 
(5 to 8 cm.). This is of the greatest diagnostic import- 
ance, for it shows that the largest diameter of the head 
has passed the inlet. The head is firmly wedged in the 
pelvis and cannot be pushed upward for the purpose of 
performing version. 

By the expulsive action of the uterine contractions 
(labor-pains) reinforced by the abdominal muscles, and the 
resistance of the coccyx and perineum (see Fig. 48), the 
spine of the ischium acting as the fulcrum, the head now 
rotates forward under the pubic arch. This rotation of 
the sagittal suture into the conjugate of the outlet, the 
contraction of the abdominal muscles, and the bulging of 
the perineum characterize the second stage or stage of 
expulsion ; the head is in the vagina. 



THE SECOND OR EXPULSIVE STAGE OF LABOR. 91 

From this time expulsion is effected chiefly by the 
acticm of the abdominal muscles; the uterine contractions 
still continue, however, and excite the abdominal muscles 
reflexly to contraction. The innervation is complicated, 
being contributed by both the sympathetic and the spinal 
system. 

The inferior strait consists reallv of two divero^ing; 
planes : the ''posterior diaphragm of the pelvis,'^ between 
the coccyx and the tuberosities of the ischium, and the 
" anterior diaphragm," connecting the bones of the pubis 
and including the rima pudendi. The pelvic outlet 
opposes but little resistance except in funnel-shaped pelves 
and in cases of anterior luxation of the coccyx. Much 
more importance, from the obstetrician's standpoint, at- 
taches to the muscles between the tip of the coccyx, the 
tuberosities of the ischium, and the lower border of the 
symphysis, which make up the pelvic floor and perineum, 
and form a sphincter-like support for the rectum, vagina, 
and urethra. 

The coccygeus muscle passes from the tip of the coccyx and 
somewhat Laterally forward on either side to the tiiherosity of the 
ischium. The sphincter ani also passes for^Yard from the coccyx 
to surround the rectum and vagina, making about eight turns, and 
after being reinforced by fibers from the transversus perincei forms 
the constrictor vaginae and inserts into the symphyseal synchon- 
drosis. The levator ani arises on the pubis, near the symphysis, 
and passes to the spines of the ischium — its fibers blending with 
the tissues of the vagina,^ which it crosses at a right angle — to the 
rectum and to the coccyx (Figs. 29 and 30). The fibers of the 
ischiocavernosus insert into the clitoris. The superficial and deep 
transversus perinsei muscles lie in the same plane and cover the 
floor of the pelvis between tuberosities of the ischium, or the 
adjacent portions of the ascending rami of the pubes. These 
muscles are, therefore, higher, that is, nearer the interior of the 
pelvis. 

The interlacing muscular bands form spaces which are bounded 
by fascise or bands of connective tissue firmly adherent to the 

1 As the connective tissue ^vhich unites the fibers of the levator ani 
with the vagina is loose, the contraction of the muscle is not sufficient to 
raise the vagina, but merely compresses it and carries it sli.shtly nearer 
the anterior wall of the pelvis. When the vulva is distended these muscles 
impart a similar downward and forward movement to the head. 



92 NORMAL LABOR. 

Fig. 75. Transverse Section of tlie Pelvis at the Level of the Internal 
Os (modified from Freund) : Six robust bands of connective tissue 
radiate forward (Lg. v. u.) to the bladder (F), laterally along the base of 
the broad ligaments {Lg. I. d. et s.) to the pelvic wall {Isch.), and back- 
ward {Lg. r. u.) to the rectum {R.) and sacrum («.). These bands are 
accompanied by bundles of smooth muscle-fibers. The intervals between 
the ligamentary bands are occupied partly by loose connective tissue 
and partly by the pelvic fossse. Close to the walls are found the pyri- 
formis {Py.) and obturator internus {obt.) muscles ; C. U., cervix uteri ; 
P., OS pubis. 

Fig. 76. Rupture of the Cervix and Vaginal Fornix, without involve- 
ment of the external os, illustrating | 6 on the attachments of the uterus 
and of the vaginal vault, and their influence on the direction of the 
line of rupture (original drawing from a preparation in the Munich 
Gynecological Clinic). 

muscles. The subperitoneal cavity of the pelvis (deep perineal 
interspace) as far as the pelvic floor and levatores ani muscles is 
filled with fat and areolar connective tissue, which communicates 
by means of open spaces with the ischiorectal or subcutaneous 
fossa. Communication is also established through the great sciatic 
notch and along the pyriformis and obturator internus muscles 
with the external connective tissue of the pelvis ; by means of 
the round ligaments Vvnth the tissues forming the mons veneris; 
and by means of the pubovesico-uterine ligament at the sides of 
the bladder with the abdominal walls. 

A knowledge of these anatomical relations is important not 
only in connection with the mechanism of labor and the attach- 
ments of the pelvic organs, but also to explain the course of sup- 
purative parametritis and paravaginal inflammation along the 
line of least resistance. 

Embedded in these masses of yielding tissue are the bladder 
and urethra, the rectum and the vagina. The highest portion of 
the latter, corresponding to the fornix, derives additional support 
from the robust ligaments which hold the cervix in position. 
Lower down the levatores ani muscles embrace the vagina, which 
extends from the external os to the edge of the hymen. This marks 
the limit of the characteristic stratified squamous epithelium 
which first appears in the sixth month of fetal life; the upper 
layer is horny, the next succeeding ones consist of swollen but 
vigorous (transitional) epithelium in process of transition from 
the columnar to the cuboid variety. In the vaginal portion of 
the cervix and in the vagina these epithelial cells in vertical sec- 
tion form a characteristic design of squares, lodging narrow^ 
stroma-papillae carrying blood-vessels. The individual cells are 
connected by a network of protoplasmic threads and contain 
large vacuoles next to the nuclei. The rugae are well developed 





6 



THE SECOND OR EXPULSIVE STAGE OF LABOR. 93 

in the virgin. Glands, if they exist at all, are represented by a 
few irregular structures, the glandaUe aberrantes arvicales et vul- 
vares. Lymph-follicles, on the other hand, are constantly found 
in connection with the richly branching lymphatic system. Foci 
of round-cell infiltration are frequently found and do not neces- 
sarily indicate the existence of a local pathological affection. 

The muscular coat of the vagina consists of unstriped muscle, 
is rich in veins, and is not distinctly separable into layers. It 
contains both circular and longitudinal fibers ; the latter pass 
over the fornix and merge into the longitudinal fibers of the 
uterus or are reflected into the portio vaginalis. The longitudinal 
fibers pass obliquely from one side of the wall to the other and 
merge into the circular fibers. The vagina does not exert an 
expulsive force, but, like the cervix and lower uterine segment, 
serves to hold back the presenting part. The submucous layer 
of connective tissue (or fibrous tissue) is richly supplied with 
nerves and a venous plexus, and on the anterior and posterior 
wall forms two conspicuous vertical folds — the columnce rugorum. 
The two columns© are not placed exactly opposite each other, the 
anterior being slightly displaced to the right, as a consequence of 
the anterior displacement of the left Mlillerian duct.^ Upon 
these columns terminate the transverse folds which constitute the 
excess of tissue designed for permitting the dilatation necessitated 
by labor. Behind the urethral orifice is a protrusion — the prom- 
ontoriura vaginae. 

The unstriped muscular coat is supported by pelvic connective 
tissue and by the muscles that have been described. The pos- 
terior fornix or retrocervical fossa is embraced by the fold known 
as Douglas' pouch (see Figs. 17, 18, 32). The axis of the vagina 
corresponds with that of the pelvic cavity (from below and in 
front to above and behind) and presents a curve with its con- 
cavity looking forward and downward. The axis of the non- 
gravid uterus, owing to its anterior inclination, makes with the 
axis of the vagina an angle of 90 degrees or less ; the external os 
rests on the posterior wall of the vagina. 

During pregnancy the papillary layer and. in fact, all the 
tissues of the mucosa, undergo marked hypertrophy, the secre- 
tions are more abundant, and the surface of the canal is roughened 
and increased both in length and in width. 

At the very beginning of gestation a marked turgescence of 
the vulva is observed, which progressively increases ; numerous 

^ Like the oviducts, which permanently retain their dual structure, 
the uterus and va.srina are at first douhle. developinsfrom two Miillerian 
cell-cords, which later become ducts, and finally fuse to form a single 
organ. In the columns described we see the physiological remains of 
this formation, while septa in the uterus or vagina are pathological 
vestiges of it (uterus bicornis, bicoUis, uterus duplex, etc.). 



94 NORMAL LABOR. 

sinuous phlebectasiae are seen in the mucous membrane, and the 
color is dark and livid ; the same appearance is noted in the 
portio vaginalis and in the fornix. 

The vulva as a whole takes both an active and a passive part 
in the mechanism of labor, the one by holding back the present- 
ing part and forcing it toward the pubic arch, the other by the 
resistance of its sh)wly yielding, elastic tissues. 

A transitional structure is the hymen, or its remains, the 
carunculae myrtiformes, which, to judge from its position and em- 
bryonal origin, probably belongs partly to the vagina (entoderm) 
and partly to the vulva (ectoderm). 

The urethra ends at the vestibule, which is bounded in front 
by the clitoris. This consists of an erectile body, terminating 
in front in a glans and prepuce, and dividing at the posterior 
extremity into the two diverging crura clitoridis, which also con- 
tain erectile tissue and are attached to the ascending rami of 
the ischium. The organ corresponds to a rudimentary penis; 
its base is flanked on either side by the cavernous bulbi vestibuli. 

The vestibule is bounded below and at the sides by the arched 
borders of the nymphse and the frenulum perinsei (fourchette). 
The surface of the former is covered with numerous papillae 
covered with squamous epithelium which follows the inequali- 
ties of the surface. The papillae are wanting in the labia 
majora. In adults sebaceous follicles are found embedded in 
both labia, in the fetus they are absent from the labia minora. 
The stroma of the labia minora is rich in vessels and nerves (tac- 
tile corpuscles of Meissner). 

The only organs in the vestibule covered with cylindrical 
epithelium are the glands of Bartholin, whose ducts measure 
from 1^ to If in. (3 to 4 cm.) and open about the lower third of 
the hymen. The perineum ends at the fourchette and consists 
principally of the muscles described and a thin layer of fat. 

The above-described complicated apparatus of soft 
structures, situated chiefly in the plane of pelvic contrac- 
tion and at the inferior strait, opposes such a resistance 
to the advancing head as to cause it to rotate forward and 
upward (Fig. 48). Propelled by the labor-pains and by 
the abdominal pressure, the head stretches and compresses 
the soft parts in a direction from above and in front 
downward and backward, so that the line joining the 
fourchette with the lower border of the symphysis makes 
a right angle with the conjugate of the inferior strait (in 
a non-pregnant woman the angle is acute). The head, 
after encountering the resistance of the coccyx, impinges 



THE SECOND OR EXPULSIVE STAGE OF LABOR 95 

on the posterior portion of the perineum, which becomes 
greatly distended and elongated. Thus, the lesser fon- 
tanel is pushed under the symphysis, while the fibers of 
the levator ani and transversus periucTi muscles, which 
are stretched to the utmost and leave the anus gaping 
wide, retract over the escaping head. The head now 
performs the third rotation about its transverse axis, in- 
creasing the distance of the chin from the chest, and re- 
volves around the si/mphi/sis ; the lesser fontanel first 
appears at the vulva, then the nape of the neck meets the 
resistance of the symphysis, and finally the sinciput, brow, 
and face, in the order named, escape over the perineum. 

This rotation of the fetal head is brought about by two 
factors : as the head is subjected to a uniform pressure it 
encounters the least resistance under the symphysis, and 
the expulsive force of the abdominal pressure acts upon 
it less through the yielding vertebral column than by 
means of a universal internal pressure (reinforced by 
the pelvic resistance) on the trunk, tending to straighten 
the fetal body. The fetal spine itself assumes an obstet- 
rical importance when, as in face or brow presentations, 
it occupies a position in which it offers a greater resistance 
to the pressure exerted from below and behind, that is, 
by the sacrum. In the ordinary occipital ])resentation 
the head remains freely movable as the pressure through 
the vertebral column pushes it toward the sacrococcygeal 
curve, so that a slight flexion suflices to allow it to ad- 
vance. In face presentations, on the other hand, the ver- 
tebral column is alreadv extended when the head reaches 
the sacrococcygeal curve, that is, the head is flexed as 
much as it can be ; if then, the chin is anterior, i. e., 
opposed to the symphysis, rotation about the symphysis 
may take place by a sinking of the chin, and the brow 
escapes over the perineum, followed by the occiput. But 
if the chin is posterior and becomes arrested in the sacral 
curve, flexion of the head becomes impossible on account 
of the overextension of the vertebral column, and labor 
comes to a standstill. 



96 THE PUERPERIUM AND NEW-BORN INFANT. 

We have, therefore, to distinguish three different kind>i 
of rotation in the birth of the head in vertex presentations: 

1. Flexion of the head about the transverse diameter, 
bringing tlie chin nearer the breast, or descent of the lesser 
fontanel, to enable the head to engage in the superior 
strait — the result of "pressure on the fetal spine ^' and 
extension of the trunk. 

2. Rotation about the vertical diameter, anterior rota- 
tion of the lesser fontanel — the result of the gradual in- 
crease of the anteroposterior diameter as the outlet is 
approached. 

3. Extension of the head about the transverse axis, 
arrest of the occiput by the symphysis, rotation of the 
occiput around the syniphysis, the effect of the resistance 
offered by the pelvic floor. 

The next step comprises the arrest of the neck and 
anterior shoulder (the right in the first vertex presenta- 
tion, L. O. A.) by the symphysis, and the birth of the 
anterior shoulder under the symphysis, followed by the 
escape of the posterior shoulder over the perineum. The 
face then turns toward the mother's thigh (the right in 
the first vertex presentation, L. O. A.). 

Similar movements of rotation are performed in all 
other straight presentations by the presenting part of the 
fetus. 

For further details and for the management of labor 
the reader is referred to the Atlas of Labor and Operative 
Obstetrics. 



CHAPTER IV. 



THE PUERPERIUM AND THE TREATMENT OF 
THE NEW=BORN INFANT. 

§ 8. PHYSIOLOGY OF THE PUERPERIUM. 

The puerperium embraces the period of retrograde 
changes in the sexual and other organs affected during 



PHYSIOLOGY OF THE PUERPERIUM. 97 

pregnancy (§ 2, table). Practically its duration is meas- 
ured by that of the most conspicuous symptom — the 
lochial discharge. The lochia represent the wound-secre- 
tion of the lacerated inner surface of the uterus, deprived 
of its epithelium and of part of the submucous connec- 
tive tissue by the separation of the placenta and the 
greater part of the decidua. 

The separation and expulsion of the placenta usually 
take place within half an hour after the birth of the 
child ; the process consists essentially in the separation 
of the fetal membranes from the uterine wall. AVe have 
seen (§ 1) that the cell-cords of the maternal decidua and 
the fetal chorionic villi are closely interwoven ; hence, to 
effect a clean separation, all the projecting processes of 
one or the other tissue must come away bodily with the 
bulk of the other tissue. As it is the network of chorionic 
villi that separate, the latter carry with them all the proc- 
esses of decidual tissue that dip in between the villi. 
The maternal surface of the placenta is accordingly fairly 
smooth, although subdivided by rather coarse furrows 
into a number of larger cuboidal aggregations of chorionic 
villi, known as cotyledons (Figs. 20, 23, 25). 

The mechanism of the expulsion of the afterbirth is 
usually as follows : first, one placental border, or a part 
near the border and the central portion of the placenta, 
or, rarely, the center alone is separated from the uterine 
wall by the muscular contraction (Atlas of Labor and 
Operative Obstetrics, Figs. 15 and 16). The space thus 
formed becomes filled with blood from the torn mater- 
nal vessels and the retroplacental hematoma results, con- 
taining on the average 7 fl. oz. (225 gm.) of blood. 
The loosened marginal portion is then forced into the 
internal os, the remainder of the periphery still adhering 
(Fig. 27), whereupon, in most cases, the entire fetal 
surface with the umbilical cord is extruded into the 
vagina and is, accordingly, the first portion to appear at 
the vulva. This, which is known as Schultze's mode of 
separation, does not, therefore, refer to the initial separa- 
7 



98 THE PUERPERIUM AND NEW-BORN INFANT. 

tion of the placenta (Fig. 26). The expulsion of the 
placenta is rarely effected throughout according to Dun- 
can's mode, in which the marginal portion, which is the 
first to separate, is also the first to be extruded ; if it does 
so happen, the membranes are not separated from the fetal 
surface. 

After the placenta has been extruded from the uterine 
cavity it may remain indefinitely in the vagina until it is 
finally expelled by the abdominal pressure, by the 
patient\s being cautiously raised to a sitting posture, or 
by Crede's method (Atlas of Labor and Operaiive Obstet- 
rics, Fig. 1 8). If the latter fails to effect its delivery it 
is probably held fast by a spasmodic stricture of the 
internal os or, more rarely, of the constrictor vaginae, or, 
in very rare cases, by inflammatory adhesions. If the 
uterine contractions are too weak to effect the separation 
the condition is usually accompanied by hemorrhage due 
to atony of the uterine muscle. 

When the uterine cavity is completely evacuated the 
womb contracts firmly and resumes its somewhat flattened 
shape ; the longitudinal muscle-bundles can be felt along 
the posterior wall. The organ is not spherical, the pos- 
terior wall is flattened ; it lies in anteflexion and the fundus 
reaches to about the lev^el of the navel. It is only when 
the uterus is relaxed that it falls backward in retrover- 
sion and is covered by coils of intestine, or is distended 
into a globular form by the inpouring blood. These post- 
partum hemorrhages from atony of the uterine muscle are 
exceedingly dangerous, especially as the woman in such 
cases is usually in a debilitated condition. 

The arrangement of the muscle-fibers described in § 5 
is such that in contracting they constrict the traversing 
blood-vessels, and effectually stop the flow of blood until 
such time as the gaping mouths of the vessels at the 
placental site are occluded by firm thrombi. The lumen 
of the uterus is very narrow and is completely filled by 
the folds of mucous membrane, the thrombosed vessels 
of the placental site, and the lochial secretion. The 



PHYSIOLOGY OF THE PUERPERIUM. 99 

cervical canal is reduced to a loose, flabby sac into which 
the thickened folds of the uterine wall protrude. It is 
most important to be able to recognize this condition 
with the palpating finger in intra-uterine manipulations 
during: the third stao;e of labor. 

In regard to the anatomy of the retrograde changes 
which take place in the uterus during the puerperal period 
more will be said later on ; for clinical purposes it is im- 
portant to reniember that, if involution is normal, the 
fundus ought to be found behind the symphysis on the 
ninth day, and on the fourth day nearly at the level of 
the umbilicus. 

The weight of the uterus on the eighth day after parturition is 
13 to 19 oz. (400 to 600 gm.) ; on the fourteenth day, 10 to 17 oz, 
(300 to 500 gm.) ; after five weeks, 7 oz. (200 gm.); after eight 
weeks, 2 to 2\ oz. (50 to 75 gm.). The greatest diminution ob- 
servable in the living subject takes place from the ninth to the 
twelfth day, when the length decreases by 1 in. (2.5 cm.), the 
breadth by f in. (2 cm.), for each day; the length, therefore, 
diminishes more rapidly than does the breadth. The retrograde 
process is one of fatty degeneration, the result of overgrowth of 
connective tissue in the media. The albumin of the muscle-cells 
is converted into peptone (discharged in urine and lochia; myo- 
metra). The blood-vessels at the placental site in part become 
occluded by thrombi, in part compressed by the contracting 
muscle-fibers. Pigment is found at this site four to six weeks 
after parturition. The formation of new muscle-fibers begins 
early. In normal cases the decidua separates only in part. A 
new epithelial covering is formed from the epithelium of the 
glands. The occurrence of involution is explained by the dimin- 
ished blood supply on account of the contraction of the organ, 
and, in part, is due to the influence of the nerve-centers. 

Two causes are active during the involution of the 
uterus : the permanent contraction of the organ, and fatty 
degeneration of the individual muscle-fibers. Both proc- 
esses are under the control of nerve-centers, hence any 
undue mental excitement must be carefully guarded 
against, as it might cause severe postpartum hemorrhage, 
or arrest the flow of milk, or at least produce chemical 
changes in this secretion. In this connection I recall a 
case in which I was summoned on the fourth day and 



100 THE PUERPERIUM AND NEW-BORN INFANT. 

Fig. 77. Distribution of the Venous Plexuses of the Pregnant 
Uterus and their relation to the arteries (modified from Heitzmann's 
injected specimen): T, tube with fimbriated extremity; Lg.l, broad 
ligament; f^^ uterus ; P, portio vaginalis ; T'^, vagina. 

Fig. 78. Distribution of the Lymphatics of the Female Genitalia 
(after Poiricr) : Ut, uterus; Ov, ovarium; T, tube; Lg.r, round liga- 
ment ; Lg.l, broad ligament ; P, portio vaginalis ; V, vagina. 

Fig. 79. Secreting Cells of Mammary Gland : 1, fatty cylindrical 
cells ; 2, spindle-cells in connective tissue ; .3, blood-vessel ; 4, duct. In 
the lumen of 1 are seen fat-granules extruded by the cylindrical cells 
(original drawing). 



found such an apparently unaccountable hemorrhage, the 
cause of which proved to be a dispute about the christen- 
ing of the infant, the mother-in-law, who was of a dif- 
ferent religion, wishing to secure it for her own faith. 
In another case the cause of the hemorrhage was the 
burning of the child's crib. The connections between the 
genital ganglia and the central nervous system are numer- 
ous (see § 5, adfinem). 

The fatty change in the muscle-cells can be demon- 
strated with the microscope ; the cells become filled with 
fatty granules during the puerperium, later the granules 
disappear and the muscle-fibers are much reduced in size. 
The process is associated with lessened blood-supply and 
histological changes in the vessels : diminution of the 
lumen by overgrowth of the connective tissue in the 
intima and fatty degeneration of the media. Macroscop- 
ically the adnexa, especially the venous plexuses and 
Ivmph-channels of the broad ligaments, are seen to be 
overfilled until tlie end of the first week of the puer- 
perium. The lymph-channels perhaps participate along 
with the lochia in the removal of the products of de- 
generation in the muscle-fibers. The slowing of the 
pulse, which is physiological, is to be attributed to the 
presence of fat in the blood, while the other product, pep- 
tone, has been found in the urine. Both diminished 
pulse-rate and peptonuria, however, sometimes occur in- 
dependently of involution. 




00 





PHYSIOLOGY OF THE PUERFERIUM. 101 

The veins form plexuses which, in the main, follow the branches 
of the uterine arteries and empty into the internal iliac vein. 
The pampiniform (or spermatic) plexus lies in close relation with 
the tube and joins the internal ovarian vein, consisting of two 
branches which, after uniting, empty into the renal vein on the 
left side, and directly into the inferior cava on the right. If there 
is loss of vasomotor tone or venous stasis the veins in the broad 
ligaments form a varicocele. 

The lymphatics originate partly near the uterine glands and 
partly in the subperitoneal connective tissue, traverse the broad 
ligament, and terminate within the internal iliac and inferior 
inguinal glands of the pelvis and in the inguinal glands. 

If the uterine cavity is invaded by pathogenic germs, 
these two channels furnish the paths by which either the 
toxins or the bacteria themselves are carried to other parts 
of the body. Either the thrombi which form in the 
placental vessels become infected and undergo decomposi- 
tion as far as the junction of these vessels with the vena 
cava and renal vein, where septic emboli are detached, 
enter the systemic circulation and become arrested in the 
pulmonary system, or the germs make their way through 
the uterine walls along the lymph-channels and, through 
the agency of the subserous, ovarian, intraligamentary, 
and other vessels, infect the surrounding connective tissue 
and the peritoneum, giving rise to ijara- and perimetritis. 

These different forms of infection are all included in 
the general term '^ ptierperal fever.'' 

The organism itself possesses efficient means of defence 
to protect itself against the invasion of such pathogenic 
germs, and an active offensive armor to render them harm- 
less after they have gained access to the body. 

The former is found in the anatomical and physical 
arrangement of the vulva, vagina, and cervix, and in the 
chemical properties of the secretion of the vagina and 
cervix ; the latter includes alexins (antitoxins), or bacteri- 
cidal substances in the blood-serum, and the germicidal 
properties of the leukocytes and of the epithelial and 
other cells. 

The obstetrician should not only guard against the 
entrance of bacteria into the genital tract, above all, the 



102 THE PUERPERIUM AND NEW-BORN INFANT. 

uterine cavity, with the greatest care, but should also take 
the proper precautions to preserve the efficiency of the 
alexins (antitoxins) in the blood and in the genital secre- 
tions. The integrity of the former is preserved by keep- 
ing up the general health of the patient, by preventing 
the occurrence of hemorrhage or fever, and by avoiding un- 
duly protracted labor in cases of contracted pelvis, and by 
removing as speedily as possible any disease that may be 
present during pregnancy, especially nephritis, failing 
compensation in valvular lesions, or continued dyspepsia. 

To guard against deterioration of the genital secretions 
it is necessary to remove any inflammation of the mucous 
membrane, especially endometritis, before the onset of 
labor. Strong antiseptic or caustic solutions should never 
be used sub partu to irrigate the vagina ; in making gen- 
ital examinations care must be had to avoid wounding the 
tissues around the internal os ; the membranes must not 
be ruptured too soon — in fact, every means must be em- 
ployed to facilitate the descent of the presenting part as 
much as possible, and to obviate any cause for avoidable 
disturbances of the circulation in the genitalia, such as 
allowing the head to become wedged against the lateral 
w^alls of the pelvis, insufficient or tardy rotation, and 
unskilful handling of the forceps in breech presentations. 

The genital secretion is found in the tube, in the uterine 
cavity, in the cervical canal, and in the vagina ; the 
greater part of it is produced in the three first-named 
structures, that found in the vagina mostly originating in 
the cervix. The amount of secretion present in a healthy 
virgin in all these parts is exceedingly small : merely a little 
mucus in the tubes and in the uterus ; and in the vagina 
a small quantity of dry, granular detritus of cast-oif 
vaginal epithelium, Avhich becomes slightly more milky 
shortly before and after menstruation. Even in healthy 
married women but little secretion is found except during 
periods of congestion, such as menstruation and pregnancy. 
The vaginal detritus is mixed with small quantities of 
mucus from the cervix ; the cervix itself is occupied by a 



PHYSIOLOGY OF THE PUERPERIUM. 103 

plug of glairv mucus, which, according to Kristeller, 
assists in fertilizing the ovum, as it is forced into the vault 
of the vagina when the orgasm is at its height, and after 
being loaded with spermatozoa is drawn back into the 
cervix by virtue of its viscidity. 

Examinations of mucus from healthy tubes and from 
the uterine cavity show that it is sterile, i. e., free from 
pathogenic germs. The same is true, in most cases, of the 
upper two-thirds of the cervical canal, which is closed by 
a plug of tough, glairy mucus, preventing the entrance 
of bacteria (Ahlfeld) and covered near the external os by 
a layer containing leukocytes. The latter are undoubtedly, 
as Walthard has pointed out, placed there to stand guard 
at the entrance of the uterine cavity, since immediately 
below them, in the external os, a narrow zone containing 
large numbers of bacteria can be demonstrated. The 
vagina soon after birth becomes the abiding-place of 
numerous germs, which grow more and more plentiful as 
the introitus is approached. Some of these germs are 
pathogenic, although in healthy individuals with normal 
genitalia their virulence is very slight (Walthard, Ahlfeld, 
Vahle, Kottmann). Still, they are unquestionably there, 
and any complication during labor may alter the conditions 
of their surroundings so as to increase their virulence and 
lead to the infection of the uterine cavity (thrombosis of 
the uteroplacental vessels) or of any other solution of 
continuity in the mucosa of the genital tract ; in other 
words, may set up puerperal fever. Such altered condi- 
tions include, for instance, lacerations and the presence of 
putrescible organic matter (dead fetus, contused tissues). 
Another favorable medium for the growth of bacteria is 
furnished by the gonococcus, which in itself is also capa- 
ble of producing puerperal febrile conditions. But by far 
the most frequent and, from a practical standpoint, the 
only source of infection worth considering is lack of 
cleanliness in digital explorations. The dangers from this 
source increase in direct proportion to the duration of 
labor, the presence of complications, and the favorable 



104 THE PUERPERIUM AND NEW-BORN INFANT. 

Fig. 80, Mammary Gland of a Blonde Primigravida, in the Seventh 
Month (original water-color). — Striae ; turgesceuce of the nipple and of 
the entire breast, which does not hang down ; moderate pigmentation 
of areola ; so-called "milk-veins" seen through the integument. 

Fig. 81. Necrotic Decidua (see § 12). 

condition of the soil for pathogenic germs. All the 
bacteria which have their habitat about the external geni- 
talia have been found within the vagina ; they include the 
Streptoco(;cus pyogenes (a non-pathogenic streptococcus is 
also found), Staphylococcus albus and aureus, Bacterium 
coli commune, occasionally Frankel's pneumococcus, which 
is found even in pyosalpinx, and Loffler's diphtheria 
bacillus (another non-specific bacillus resembling the latter 
has also been found). In addition to these there is pres- 
ent as a constant inhabitant Doderlein's bacillus, the thick, 
rod-shaped organism to which the bactericidal acid reac- 
tion of the vaginal mucus is attributed, though it is not 
always bactericidal, and, finally, large numbers of so-called 
anaerobic saprophytes, which cause the putrefaction of 
retained shreds of ovum. It is important to remember 
that the bactericidal power of the genital secretions is 
much diminished or even destroyed during the first days 
of the puerperium, owing to their conversion into the 
alkaline lochial discharges. During labor, on the other 
hand, their bactericidal power is greatly reinforced by the 
presence of the amniotic fluid, which possesses the same 
property in a marked degree. Experiments with this 
fluid have shown tliat so-called anaerobic saprophytes 
cannot live in it at all, and even the pathogenic varieties 
lose their virulence. 

Kronig, with other authors, denies the presence of 
pathogenic germs (streptococci) in the healthy vaginal 
secretion of a pregnant woman. 

The lochia are divided into three physiological forms : 
lochia cruenta (rubra), consisting of blood only ; lochia 
serosa, consisting of serum with numerous leukocytes, 
nucleated decidual cells, epithelial cells, and cocci ; and 
lochia alba, serum with but few cells and cocci : 





00 



o 



PHYSIOLOGY OF THE PUERPERIUM. 



105 



Days. 
1st to 2d. 



2d to 3d. 



:3d to 5th. 



7th to 8th. 



9th. 



10th. 



Mother. 

Lochia cruenfa or rubra. Fun- 
dus almost at the umbili- 
cus ; afterpains. Liquid 
diet. 
{Lochia cruenta. congestion 
of breast. Lateral de- 
j cubitus permissible. 
Lochia serosa, tempera- 
ture : 98.6° to 100.4° F. 
(37° to 38° C.) maximum. 
Lochia alba, colostrum has 
disappeared ; placental 
site can still be felt. 
Fundus behind the sym- 
physis. 

Patient may be allowed to 
get up. 



Child. 

Line of demarcation appears 
on the navel. Greatest 
diminution in weight. 

Separation of cord ; mecon- 
ium has disappeared. 



Physiological jaundice. 



Temperature : 98.4° to 100° 
F. (36.8° to 37.7° C). 
Weight same as at birth. 

Average daily gain, 20 to 35 
grammes. 



There is a physiological connection between the lochial 
discharge and the secretion of milk, the latter beginning 
on the second to the fourth day, when the former under- 
goes a change. Conversely, an excessive lochial discharge 
influences the amount of milk secretion unfavorably. 
Massage of the abdominal walls and viscera has a favor- 
able effect on both the lochial discharge and the secretion 
of milk. 

The involution of the muscularis has been mentioned 
in § 5. The regeneration of the mucous membrane is 
marked by the gradual destruction of the decidual cells 
and the growth of a stroma rich in round cells, in which 
and from which the new glands are formed. The 
regeneration of the latter is accomplished by proliferation 
of the intact cylindrical cells in the fundi of the glands. 
These cells also produce the single layer of cylindrical 
cells which clothes the surface of the newly formed 
mucous membrane (see Fig. 87). 

The involution of the other organs of the body was 
referred to in § 2. For clinical purposes it is to be re- 
membered that the pulse of a puerperal patient is often 
exceedingly slow and soft, hence the presence of even a 
moderately accelerated pulse should excite suspicion, 
though a certain degree of irregularity is physiological in 



106 THE PUERPERWM AND NEW-BORN INFANT. 

Fig. 82. Lochia Rubra or Cruenta : 1, decidual cells ; 2, squamous 
epithelium; 3, red blood-corpuscles iu rouleaux; 4, isolated red blood- 
corpuscles; 5, leukocytes; 6, isolated cocci (diplo-). 

Fig. 83. LocMa Serosa or Sanguinolenta (numbers the same as in the 
preceding figure).— The cells are granular. 

Fig. 84. Lochia Alba : 6, masses of cocci ; 7, granular, vesicular 
spindle-cells ; 8, cholesterin plates. 

Figs. 82-84. — Drawings from original preparations. 

Fig. 85. Colostrum-cells.— Fat-droplets (1) extruded (3) from the 
fatty cells (4) (cf. Fig. 79) ; 2, leukocytes. 

Fig. 86. Milk.— The fat-droplets (1) are suspended in water ; two leuko- 
cytes are seen (2). 

Figs. 85 and 86.— Drawings from original preparations. 

Fig. 87. Section through the Wall of a Puerperal Uterus (microscop- 
ical ; original) : 1 and 2, circular muscle-fibers, some of them in a state of 
granular degeneration ; 4, loose-meshed, edematous connective tissue ; 3, 
large muscle-fibers in cross-section ; 5, a large, thick-walled vessel with 
red thrombus and beginning fibrin formation (" ribbed ") ; 6, a vessel in 
which the thrombus has become completely organized, showing lamella 
formation ; 9, large capillary vessels of the subdecidual mucosa already 
converted into connective tissue ; 7, irregularly contracted muscle-fibers 
in process of degeneration, the cells have failed to take the stain ; 8, large 
capillary vessels newly formed during pregnancy ; 10, glandswhich have 
retained their cylindrical epithelium in the depth during pregnancy; 
these cells subsequently proliferate and furnish a covering for the regen- 
erating mucous membrane ; 11, stroma of the mucous membrane contain- 
ing numerous decidual cells (12, 13) ; in one of the capillary spaces filled 
with decidual cells is seen a chorionic villus (14). 

the beginning of the puerperal period. Individual 
idiosyncrasy plays a much more important role in this 
slowing of the pulse-rate than the earlier authors were 
disposed to admit (Heil). 

As the lochial discharges diminish, the changes in the 
mammary gland culminate in the establishment of its 
true function, the copious secretion of milk (on the third 
day). 

As early as the second month, as has been mentioned 
in § 2, it is often possible to express serum from the 
nipple. The first indications of the changes brought 
about by pregnancy are observed during the first month 
in the form of tugging and stabbing pains, a feeling of 
increased weight and distention, tenderness on pressure, 



Tab. 37. 






•(-...-'^'^W'Q'O ®\' 



fe^SS?^^ 







a 



^■OQ 



?■ t>(?P'^'e0 



^i4 



/ r 



Fig. 82. 



S-^, 









:. ^ 






®'Bmck:^'P^k-o'& 



-bVQ' 



Fig. 83. 




Fig. 84. 



2 S 



cO^ 



«> 



O 



o 






C J .^ 

O " 1 



Fig. 85 






Fig. 86. 




'-4^^ 
^ 



— .y 



y^- 




Fig. 87. 



Lith.Anst F Reichhold,Mujichjen. 



PHYSIOLOGY OF THE PUERPERIUM. 107 

and the presence of radiating cords recognized by the 
sense of touch. The fifth month is characterized by the 
appearance of stri.T, pigmentation of the areola, the 
formation of a secondary areola, and l)y prominence of 
the Malpighian glands. The epithelium of the acini 
proliferates and forms new glandular structures, while 
the interlobular connective tissue swells and becomes 
looser ; fat begins to form in the interstices between the 
fifteen to twenty-four cake-like lobes of each gland, the 
ultimate lobides of which correspond to the above-men- 
tioned glandular acini. The ducts of the individual lobes 
unite at the nipple and together form the lactiferous sinus. 

The cells of the glandular epithelium are polyhedral, somewhat 
flattened, and granular ; they are separated from the lymph- 
channels by a small amount of connective tissue, which cor- 
responds to the tunica propria, and a layer of endothelial cells 
outside of the latter. 

During pregnancy the cells become taller, more cuboidal, mul- 
tinuclear, and contain more albumin; fat-droplets collect in their 
free border near the lumen of the acinus, and are discharged 
along with the peripheral portion of the cell (Fig. 79). 

We find such alveolar cells filled w4th fat-granules in the 
colostrum, where they constitute the colosf rum-corpuscles (Fig. 
85). They are found in the milk until the fifth day of the puer- 
perium, and by their rupture the suspension of the fat-droplets 
in the milk-serum is accomplished ; the process begins in the 
milk of the third and fourth days (Fig. 86). The delicate so- 
called '*' haptoofenic membrane " of the milk-globules has no actual 
existence. Milk is a simple emulsion of fat-droplets. Leukocytes, 
isolated pale cells, and fission-fungi (staphylococci; are also found 
in milk. 

Composition of Human Milk : 



Xeic. 




Old. 


(Fifth day after delivery.) 


iFiv 


6 months after delivery.) 


1.52 0.9 




3.92 casein. 


3.28 3.3 




3.66 fat. 


5.38 6.8 




4.36 susar of milk. 


0.30 0.2 




O.U salts. 


2.-5 




0.38 albumin. 
0.13-0.33 peptone. 



In addition the milk contains urea, lecithin, and cholesterin. 
Dailv quantity 1 to 3 pints (500 to 1500 c.c.) ; specific gravity 1026 
to 1036. 



108 THE PUERPERIUM AND NEW-BORN INFANT. 

Colostrum contains principally albumin, which is converted 
into casein in the milk and is coagulated as such by boiling or 
precipitated by rennet : it also contains salts — magnesia, calcium 
phosphate, common salt, and chlorine — which act as laxatives to 
assist in the evacuation of meconium. 



I 9. PHYSIOLOGY AND FEEDING OF THE NEW=BORN 

INFANT. 

The natural and only ^' ideal '^ food for the nursling 
is its mother's milk, providing the mother be well and 
strong, and neither markedly neurasthenic nor hysterical. 
It is better than the milk of a wetnurse for several rea- 
sons : in the first place, the time of delivery is rarely the 
same in the wetnurse as in the mother, and the chemical 
concentration of the milk is thereby materially affected ; 
in the second place, one can never be sure of the consti- 
tution, past history, and general character of the wet- 
nurse ; and, in the third place, it cannot be doubted, 
although the question is not susceptible of proof, that the 
milk of its own mother, providing she be healthy, is 
always the one best adapted to the infant's needs. Chil- 
dren brought up on their own mother's milk not only 
appear to thrive better, but show a greater power of re- 
sistance, both during infancy and in later life. In other 
words, they acquire a more vigorous constitution. 

The best criterion of an infant's well-being is its gen- 
eral habit and, above all, its body weight. The new-born 
infant for some time after birth must be regarded as a 
relatively immature creature, especially as compared with 
the young of most mammals. Its volitional acts during 
the first weeks of life are exclusively limited to the regu- 
lation and performance of vegetative functions. Thus 
the separate organs of the body, as they gradually ap- 
proach a state of independence, acquire the necessary tone 
and power of resistance to enable them to withstand del- 
eterious influences from without. Hence the index of the 
infant's growth is found not only in the increase of the 
body weight itself in proportion to its growth and its in- 



PHYSIOLOGY AND FEEDING OF NEW-BORN INFANT. 109 

crease in size, but particularly in the increased density 
of the individual organs by the deposition of the essential 
tissue-elements on which their functions depend. Since, 
however, all the " vegetative^' organs, with the exception of 
the lungs, are activeduringthe last monthsof fetal life (heart 
and vascular system, liver and bile secretion, renal and 
even gastric and intestinal secretion ; the fetus even per- 
forms the act of deglutition, as shown by the lanugo 
hairs which find their way into the intestine along with 
the amniotic fluid), they are found to have reached a cer- 
tain stage of development in the new-born, so that the 
important process of nutrition and digestion can begin at 
once. 

The brain at birth possesses relatively the lowest specific 
gravity of any of the organs. 

As regards the morphology, the formation of the first fissures is 
not observed until the seventh or eighth fetal month ; at birth 
the convolutions are already fairly well developed. The tissue- 
elements, however, and the chemical composition are in a very 
undeveloped state. Although the brain appears to keep pace with 
the other organs and with the entire body in regard to bulk after 
the fourth fetal month, its weight is relatively much lower, the 
specific gravity being even less than that of the blood, hence the 
brain of a new-born infant contains a greater percentage of water 
than does its blood. This condition, however, undergoes a rapid 
change during the first year of life, the specific gravity of the 
brain increasing as the psychical functions are awakened. 

Like the cerebral functions, volitional movement of 
the muscles of the limbs and trunk remain in abeyance 
during intra-uterine life. The so-called ^' fetal move- 
ments,'' which are felt after the fourth fetal month, both 
by the mother and by the hand of the examiner, represent 
merely reflex movements and are in no sense purposeful. 
Although they appear to be quite forcible, the amount 
of muscular exertion is reallv very sbVht, as the amniotic 
fluid in which the child is suspended is quite high in 
specific gravity and, therefore, permits the trunk and limbs 
to be moved with very little exertion. 

The histological changes which occur in the first days of life, 
as muscular activity begins to be established, are such as we 



no THE PUERPERIUM AND NEW-BORN INFANT. 

should expect to find. The muscles of the fetus and of the new- 
born infant are pale in color and very quickly become fatigued 
after electrical stimulation. In other words, they go into fatigue- 
cramp, and this probably explains why the new-born infant is so 
subject to convulsions; if we make a tracing of the muscular con- 
tractions in new-born infants, we find that the curves resemble 
those of fatigued muscles in an adult. Under the microscope 
these pale muscles present only transverse striations ; whereas, 
the muscles of children five to eight days old are not only of a 
deeper red color but also show both longitudinal and transverse 
striations very plainly. 

The rapidity with which calcium salts are deposited in 
the skeleton may be judged by the speedy hardening of 
the bones of the skull, which at birth are still quite com- 
pressible, and by the rapid closure of the sutures and fon- 
tanels, in spite of the active growth of the brain and 
calvarium. If the food contains an insufficient amount 
of calcium salts, rachitic softening of the bones results, 
or at least the closing of the fontanels is delayed beyond 
the first year, giving rise to parchment-like crepitation 
of the flexible and movable cranial bones. 

This consolidation of the tissues is the sole occupation 
of the new-born infant during the first weeks of its life. 

The establishment of the sense of sight is the first sign, as it is 
the principal factor in the awakening of the psychical life. The 
time of its appearance is subject to variation, depending on indi- 
vidual development and particularly on the general bodily health. 
Thus the baby will begin to stare at a conspicuous object in its 
second month, although reaction to a bright light is established 
very soon after birth, and there is an evident appreciation of loud 
sounds and of the taste of very irritating substances, such as qui- 
nine. During the third and fourth months the infant begins to 
appreciate finer differences by the sense of sight, and in the sixth 
month by the sense of hearing. The tactile sense is strongly 
developed from the beginning, especially about the mouth. 

In debilitated, sickly, or insufficiently nourished children, the 
awakening of conscious sensations, of perceptions by the special 
senses, of conscious imagination, and, finally, of conscious mem- 
ory, is delayed until a later period. 

At the moment of birth a profound revolution takes 
place in all the organs. Whereas, up to this period, the 
purification of the infant's blood, the process of supplying 



PHYSIOLOGY AND FEEDING OF NEW-BORN INFANT. Ill 

it witli matured products of metabolism, and the function 
of respiration (rece})tion of oxygen, as well as elimina- 
tion of carbon dioxide) is performed exclusively by the 
mother, and even the infantile circulation is materially 
assisted by the uterine tonus which reacts on the vessels 
of the chorionic villi — from the moment of birth the 
childish or2:anism is thrown entirelv on its own resources. 
Not only is the heart called upon to do its work alone, 
but this work is materially increased by the fact that, as 
pulmonary respiration begins, the entire mass of blood 
has to be forced through the intricate system of pulmonary 
capillaries, where the altered blood-current encounters a 
new and considerable resistance. 

At each inspiration (which at first is of little importance in 
respect to respiration) the lungs take up large quantities of blood 
into the capillaries of the pulmonary arteries, which now contain 
blood from the right ventricle instead of carrying it directly to 
the aorta through the ductus arteriosus. The ductus arteriosus 
is therefore superfluous and becomes obliterated about the end of 
the third month. The pulmonary veins convey the first oxygen- 
ated blood back into the left auricle of the heart; this produces 
a rise in pressure which prevents the entrance of mixed blood 
from the right auricle; all the blood goes into the right chamber 
and from there into the pulmonary arteries, and the lesser circu- 
lation is established, closure of the valve of the foramen ovale 
begins and is completed in from sixty to eighty days. The fetal 
circulation has become converted into the infantile circulation. 

As has been mentioned, the digestive organs of the 
new-born infant secrete small quantities of ferments capa- 
ble of decomposing both starch and albumin ; hence, we 
have a scientific proof of the possibility of digesting 
starches, which is an important point in artificial feeding. 
Human milk is so accurately adapted to the needs and to 
the chemical powers of assimilation of the stomach and 
intestine that only very healthy human infants can digest 
unprepared cows' milk. Cows' milk contains much more 
casein than does human milk ; the amount of pepsin con- 
tained in the human stomach is not sufficient to digest this 
casein and render it fluid, hence the casein does not get 
beyond the stage of coagulation in the acid gastric secre- 



112 THE PUERPERIUM AND NEW-BORN INFANT. 

tion, and passes into the intestinal canal in the form of 
curds, which are frequently vomited. These solid particles 
irritate the mucous membrane and form a favorable medium 
for the development of any pathogenic micro-organisms 
that may have entered with the food. 

Asses^ milk or goats' milk is best adapted to the human 
infant, but it is difficult to obtain. 

But although the milk of animals may be harmful, it 
may be preferable to the mother's milk if the quality of 
the latter has deteriorated by reason of the mother's ill 
health or a sudden nervous disturbance, such as fright, 
anger, or convulsions. Under these conditions the milk 
may make the child vomit or set up a diarrhea, with 
attacks of colic or even general convulsions. 

It is, of course, evident that the infant must possess 
some natural means of protection against such accidents ; 
they are, however, subject to great individual variations. 
They depend on the inherited fetal energy, the congenital 
power of resistance, in short, that which is known as 
'^ constitution." The simplest and most reliable means of 
determining this resisting-power consists in weighing the 
child regularly every week. The factors which determine 
the body weight and power of resistance of the infant 
during the first months of life are somewhat complex. 

It has been said that the period at which ihe special senses first 
make themselves manifest in infants depends on the individual 
progress in the development of the entire body, which again is 
influenced by the inherited constitution and the care and feeding 
of the infant, and that the first weeks of life are entirely devoted 
to building up the resisting power of the whole organism, so as to 
enable it to withstand the transition from fetal to independent 
metabolism. The body weight is not only an index of the infant's 
growth and general development, but it also furnishes us with the 
means of determining any arrest of development due to some 
obscure lesion, the cause of which may not necessarily reside in 
the child or in its food or even in the constitution of the parents, 
but may be a temporary injury to the mother during pregnancy 
or at the time of conception, such as illness, mental trouble, alco- 
holic abuse. Thus the latent stage of a disease may be revealed 
by a sudden fall in the body weight before any symptoms become 
manifest. 



PHYSIOLOG Y AND FEEDING OF NEW-BORN INFANT. 1 1 3 

If we take a series of healthy children born of healthy 
parents and examine the changes in weight, from the first 
days of life, we find that the body weight undergoes typi- 
cal variations, and if we represent these variations by a 
curve we find a marked decline immediately after birth, 
the lowest point being reached on the third day of the 
infant's life. From this point the curve gradually rises; 
but, according to my investigations, not more than 14 per 
cent, of all the children regain their original weight by 
the end of the first week ; many do not reach this point 
before the seventh or even the tenth day, while in 44 per 
cent, the weio:ht at the end of the second week is still 
lower than it was at birth. 

The cause of this loss of weight is to be sought in the 
metabolic processes. I compared the absolute weight of 
the ingested milk with the total amount of intestinal and 
renal excretion, to which I added the liquid and gaseous 
and metabolic products excreted through the skin and 
lungs, with the following result : ^ 

From the first to the third day (inclusive) : 
10 oz. (+ 300 gm.) ingested milk. 
15 oz. (—453 gm.) excreted products of metabolism. 
5 oz. (— 153 gm.). 

Five ounces (153 gm.), therefore, represents the apparent loss in 
body weight. As a matter of fact, however, ihe average loss dur- 
ing these three days amounts to 11 oz. (337.6 gm.), which leaves 
6 oz. (184.6 gm.) of tissue consumption to be accounted for. 

For the period from the fourth to the seventh day (inclusive) I 
obtained the following figures : 

Total amount ingested, 50 oz. (+ 1539 gm.) milk. 

Total amount excreted, 32f oz. (— 1013 gm.) metabolic products. 

Apparent increase in body weight, 17^ oz. (+526 gm.). 

Actual average increase in weight, 7 oz. (+ 210 gm.). 

Again the increase in weight is less than would be expected 
from the calculation, and there remain 10 oz. (316 gm.) of tissue 
consumption to be accounted for. 

In accordance with the relatively low functional activity, 
the fetus generates, as we have seen, only a slight amount 
of heat of its own. As soon as the fetus is born it loses 

^ Reported at length in Arch. f. Gyn., 1897. 



114 THE PUERPERWM AND NEW-BORN INFANT. 

a large proportion of this heat by radiation, but this loss 
is made good by the establishment of many new functions 
which, by the chemical and physical processes to which 
they give rise, generate a considerable amount of warmth 
and of gases — the chief factors in this heat production 
being the pulmonary and cutaneous respiration, the diges- 
tive processes, and chemical cell-activity. Hence the ex- 
cess of ingested milk, as seen above, is used for this heat 
production and not for the purpose of building up the 
body by increasing the body weight. 

The disproportion between the amount of nutriment 
supplied in the milk and the loss in weight, or the unex- 
pectedly low increase in weight during the first eight or 
fourteen days, is therefore explained by this consideration 
of the heat-producing power of the milk and of cutaneous 
radiation ; in other words, by the heat production. 

As during the first three days the amount of milk ingested is 
not sufficient to maiatain the necessary degree of heat, and as the 
rapidity with which the organs in general accustom themselves 
to the performance of their new functions is subject to individual 
variations, the body during this time consumes its reserve sup- 
ply of material derived from the mother. Thus I found that 
the weight-curve corresponded with the temperature-curve and 
with the curve representing the total amount of nitrogen excreted 
in the urine. This phenomenon undoubtedly explains the so- 
called physiological icterus which is so often seen in infants in the 
first week, and which is probably due to the destruction of large 
numbers of red corpuscles (Hofmeier). 

The body temperature is extremely variable during the 
first few days, as heat production and heat radiation have 
not yet become properly regulated. 

The temperature of the skin in the infant is 77° to 84.2° F. (25° 
to 29° C.) as against 89.6° to 93.2° F. (32° to 34° C.) in the adult, 
because the radiation in the former is so much more active. Thus, 
I found the temperature on the epigastrium in an infant which 
had been clothed as usual on the average 97° F. (36.1° C.) during 
the first week (in boys slightly higher than in girls), while in 
adults it is only 95° F. (35° C). This shows how important it is 
to guard the infant against any loss of heat while Schultze's 
method or other similar manipulations are performed for the pur- 



PHYSIOLOGY AND FEEDING OF NEW-BORN INFANT. 115 



CT" — CO to —i 

■2. - ^ Oj -^ 



^ 

o 



53 



B 

I 

S" 



9 

a 



"3 X 



^ X 9 X 



jc -n. n t: 



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— r* 



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3^ '^ 






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116 THE PUERPERIUM AND NEW-BORN INFANT, 

pose of establishing respiration, especially as the rapidity of the 
cooling process increases as the temperature falls. 

The loss of heat experienced from the time of birth 
until the first bath has been given is enough to produce 
a fall in the body temperature from 99.3° F. (37.4°C.) to 
96.8° F. (36° C.) and 95° F. (35° C). The fetus, and 
similarly the new-born infant, immediately after birth and 
until the heat balance has been established, behaves like 
a poikilothermic animal or like those mammals which are 
born blind, since the heat-producing power is still at its 
minimum. Hence it is that during the first weeks of life 
ingestion of milk and the first crying spell are immedi- 
ately followed by a rise in the body temperature. 

The temperature varies physiologically from 97.8° to 
98.6° F. (36.5° to 37° C). 

These, then, are the factors which influence the general 
physiological changes in weight. An unusually well- 
developed infant (over 8| lb. [4 kilos]) does not show 
these changes to the same extent as does a normal child 
of average weight (6| to 7^ lb. [3100 to 3400 gm.]), the 
loss in weight on the fourteenth day being IcvSS while the 
increments are greater ; on the other hand, a Aveakly or 
premature child is affected very much more unfavorably, 
and is also much more apt to be attacked by icterus. 

The influence of the mother manifests itself in the fact that 
the children of primiparse, under the age of twenty and weighing 
less than 120 lb. {bo kilos), show the least tendency to increase 
their weight during the first week, and the same is true of the 
children of mothers who are obliged to work hard during preg- 
nancy and who are not able to nourish themselves properly or are 
attacked by disease. This relation between the mother's condi- 
tion and the size of the fetus enables us, if necessary on account 
of a contracted pelvis, to influence the weight of a fetus during 
pregnancy by dietetic methods (Prochownik's diet). 

Conversely, the greatest tendency to increase of weight is found 
in children born of women weighing over 120 lb. (55 kilos) and 
between the ages of twenty and twenty-nine, especially of multi- 
parae; the latter also produce on the average more boys than girls. 
Vigor in the father usually compensates for the maternal weak- 
ness in the matter of the' infant's weight ; even the temporary 
condition of the father at the time of impregnation has some in- 



PHYSIOLOGY AND FEEDING OF NEW-BORN INFANT. 117 

fluence in this respect. In marriages between different races the 
peculiar qualities of race, nationality, or tribe manifest themselves 
in this matter of the child's weight; thus, marriages between 
Ano-lo-Saxon men and Japanese women usually result untavorably 
for Uie mother, because the broad skull of the infant is unable to 
pass the narrow and circular pelvis ; on the other hand, marriages 
between Anglo-Saxons and Latins usually give favorable results. 

These relations affect the absolute weight of the child 
at birth as well as the subsequent changes in weight ; the 
greater the body weight of a vigorous, healthy mother, 
the greater is the average increase in the weight of the 
child ; although there are certain typical differences in 
the average weight, depending on whether the child is 
the first-born or not, the first-born being usually the 
lightest. 

The children of tuberculous or scrofulous mothers show an 
average deficit of 6.2 per cent, of their initial weight as late as 
the fourteenth day, as against 0.14 per cent, in children born of 
healthy mothers ; while the latter put on weight at the average 
rateof- Uoz. (35 gm.) per day during the first month, and 1 oz. 
28 gm.) per dav during the second month, the children ot_ tuber- 
culous mothers on the average show no increase at all during the 
first month and only 62 gr. (4 gm.) per day during the second 

"^ The* average weight of children of healthy and of diseased 
fathers is represented by the following proportion: 124:92 oz. 

(3500 : 2600 gm.). , -ui. ^i^A,, 

Diabetes in the mother exerts an even more unfavorable ntlu- 
ence than do the diseases just mentioned; 5 per cent, of children 
born of diabetic mothers die before term. 

The same is true of syphilitic transmission. Children born of 
syphilitic mothers who are healthy at birth and remain healthy 
show a much smaller increase or a greater decrease in weight on 
the average than the children of healthy mothers This may be 
accounted for in part, but only in part, by the artificia feeding. 

Heavy children-over 8f lb. (4 kilos)-are more ?ften.borb 
even from primiparse, among the better classes than m lyingyin 
hospitals. This is due to over-feeding during pregnancy and in- 
sufficient bodilv exercise. • 4. +i.^ ^^ 

It should also be mentioned that nature often assists the ott- 
sprino- of debilitated mothers at the latter's expense. Ihus, the 
child?en maybe born perfectly healthy, even ^vhen the mother 
during pregnancy was insufficiently nourished ^^^^^^^y' ^^^^Xn 
the birth of her infant the mother suddenly collapses and often 



118 THE PUERPERIUM AND NEW-BORN INFANT. 

does not recover for months, even with the most careful nursing, 
or else does not recover at all and falls a victim to tuberculosis. 

A knowledge of these facts is important in determin- 
ing the prognosis of a birth in cases of contrac^ted pelvis 
and the probable effect of methods of feeding on the 
infant. 

In general, artificial feeding in healthy children is 
never or hardly ever followed by the same increase in 
weight and general improvement as when the child is fed 
from the breast. 

If we compare the body weights of healthy children brought 
up by Soxhlet's method with that of breast-fed children we find 
that the former regain their initial weight on the fourteenth day 
very much more rarely than do the latter; we also find a greater 
average decrease in weight : 7.3 per cent, as against 5.5 per cent. 
— yielding an average of 3.7 per cent, instead of 0.14 per cent. 
(In Soxhlet's method — sterilization — the milk, after being diluted 
with water and enriched with sugar of milk to make it more like 
human milk, is boiled from ten to twenty minutes for the purpose 
of killing fermentation fungi and tubercle and other bacilli). In 
the urine the loss of phosphorized albuminates in the form of 
pseudonuclein from cow casein has been demonstrated. Mother's 
milk is very completely utilized by the new-born during the 
second week, as shown by the following table (Mischel, Uffelmann, 
Wegscheider) : 

Nutritive substances in general 96.11 per cent. 

Fat 96.35 '' 

Nitrogenous substances . 93.60 

1.486 gm. mineral salts 78.26 " 

.243 gm. calcium 59.42 

.263 gm. phosphoric acid 91.63 " 

Breast-fed children show a daily increase of about 1 oz. 
(30 gm.) during the first and second months, while those 
fed artificially show at first only 6 drams (23 gm.) and 
later 5 drams (1 9 gm.). We have already shown how easily 
the digestive function may be disturbed in artificial feed- 
ing, either by the inability of the child to digest the casein 
or by the occurrence of an infectious gastro-enteritis ; 
if, however, the infant remains well^ the loss of weight is 
made good during the second half of the first year, when 
every child is capable of assimilating a mixed diet. In 



PHYSIOLOGY AND FEEDING OF NEW-BORN INFANT. 119 

any case the injurious effects of artificial feeding, which 
rarely fail to put in their appearance during the first six 
months of life, tend to diminish the resisting power of 
the infantile organism. As the infant in this early stage 
is quite capable of digesting prepared starch (that is, to 
convert it into soluble sugar), as has been shown by ex- 
perience as well as by the latest investigations, we are 
quite justified in adding prepared farinaceous foods to the 
milk as early as possible, whenever the milk alone proves 
insufficient. The oldest preparation of this kind is 
Nestle's infant food, consisting of sterilized milk thick- 
ened with a kind of zwieback meal and a little cane- 
sugar. I have also obtained good results with Fiirther^s 
" Kinderzwieback,^^ with similar preparations manu- 
factured by Kufeke, by Wagner of Stuttgart (whose food, 
however, gives the urine an irritating quality that some- 
times causes intertrigo), and, finally, by Theinhardt. Oat- 
meal mixed with boiled zwieback meal often answers the 
same purpose. Recently malt-soup has been given with 
some success to marasmic infants, and as early as the first 
week to infants suffering from gastro-intestinal disease. 
(To 24 oz. — 750 gm. malt-soup add 5 oz. — 150 gm. of 
water, so that it contains a smaller proportion of milk 
and flour and a greater proportion of malt extract than 
Liebig's extract.) 

As we have seen, the new-born infant requires a large 
amount of heat-producing substances — 3 J oz. (100 gm.) 
of albumin (the casein in cows' milk is very much in ex- 
cess of that contained in human milk and is practically 
indigestible for the child) yields only as much heat as 
l-J oz. (52 gm.) of fat, hence the infant's digestive tract 
is at first better adapted to the assimilation of milk rich 
in fat and poor in albumin. By the process of centrif- 
ugation a part of the casein can be mechanically re- 
moved from cows' milk ; hence the question of artificial 
feeding is theoretically, at least, best solved in this way. 
Any dairy can manufacture this Gartner's ^' Fettmilch " 
by means of the centrifugal machine, and the use of this 



120 THE PUERPERIUM AND NEW-BORN INFANT. 

modified milk undoubtedly yields very good results, but 
it is far from realizing the ideal of an artificial food. I 
have seen many children who were fed on this prepara- 
tion fail to gain weight as they should, when the addition 
of the above-mentioned substances produced satisfactory 
results. 

The best method of preparing artificial milk is that 
of Heubner-Soxhlet, and it can be prepared from good 
fresh cows' milk as it is delivered at our doors every day. 
The milk is boiled for from ten to twenty minutes (if the 
milk is boiled longer than this it becomes even more in- 
digestible than it was at first), and after having been 
diluted according to the age of the child in the propor- 
tion of 1 : 3, 1 : 1, and, finally, 3 : 1, is enriched by 
the addition of 5 per cent, of milk-sugar (sterilized and 
chemicallv pure preparation of Loflund), temperature 
95° F. (35° C). 

The milk is to be well shaken before it is poured into 
the bottles supplied with Soxhlet's apparatus, and contain- 
ing from 2 to 6^ fl. oz. (50 to 200 c.c), so that each bottle 
may contain the same percentage of fat. 

After the mixture has been })repared according to the 
table, the entire battery of bottles is boiled at once from 
ten to twenty-five minutes, and the bottles are then closed 
with the automatic air-tight stoppers. The latter are not 
essential ; it is far more important to cool the milk at 
once, although there is some danger of breaking the bot- 
tles. To avoid expense the mixture may be boiled in an 
ordinary pot, the directions being carefully followed. 

It is one of the most important duties of the state to keep up a 
high standard of cattle by constant addition from healthy dis- 
tricts and the importation of good Swiss and Dutch or other 
breeds from low countries, to insist on proper feeding and care, to 
discourage the custom of keeping cows in stables or pasturing 
them on lands overgrown with weeds unfit for the production of 
milk, and, finally, to exclude all but the best quality of milk from 
the general market, as was done with great success by a private 
individual in Berlin. Like many other hygienic regulations this 
matter should be subject to the immediate supervision of public 



PHYSIOLOGY AND FEEDING OF NEW-BORN INFANT. 121 

boards of health. The inability to nurse children is increasing to 
an alarming extent in many regions ; even the rural population is 
deteriorating in this respect, and a dearth of wetnurscs is begin- 
ning to be felt. Physicians nowadays often meet with country 
women suffering from so-called nervous dyspepsia, chlorosis, and 
neurasthenia, symptoms which are without exception to be attrib- 
uted to diminished powers of resistance. 

The relative deficiency in carbohydrates in the milk 
mixture M'hich I have described is corrected by the addi- 
tion of 5 to 6 per cent, of milk-sugar. In spite of this, 
however, most children do not thrive as they should, and 
if the number of feedings is increased^ or more concen- 
trated milk is used, the digestion usually suffers. In such 
cases the preparations of milk and zwieback meal should 
be resorted to, or, if possible, a good wetnurse should be 
procured. This is often difficult, troublesome, and expen- 
sive, as it is not always possible to be sure of the health 
and moral fitness of a wetnurse, but if these conditions 
can be obtained, it is the most rational method of feeding. 
From an ethical point of view the question is frequently 
hard to decide, as it not rarely involves the entire 
abandonment of the wetnurse's child. A physician is 
never justified in procuring a healthy nurse for a syph- 
ilitic child, or even in giving his consent to such a pro- 
cedure. 

A good wetnurse should possess the following qualifi- 
cations : Her general condition must be perfect, above 
all, tuberculosis and syphilis must be excluded ; the 
breasts must be well developed, both as regards the gland- 
ular structure and the nipples. The size of the mamma 
is frequently due to excessive adipose tissue, as we often 
have occasion to see in the beer districts in Bavaria. The 
physician will do well to reserve his judgment in the case 
of an unknown nurse until the following day, as employ- 
ment bureaus very often prepare the nurses by giving 
them large amounts of beer and taking away the child ; 
the fitness of a nurse is always best determined by the 
examination of her own child. The milk should contain 
at least so much fat that after twentv-four hours one- 



122 THE PUERPERIUM AND NEW-BORN INFANT. 

tenth of the volume rises to the surface in the form of 
cream. The diet and general care of the nurse should he 
such as she has been used to before, as far as the altered 
circumstances will permit. Nurses are very apt to be- 
come lazv and careless about their persons ; they should 
be carefully looked after and made to do some light form 
of house-work. A nurse's disposition should be gentle 
and good-natured, and she must not be the subject of any 
nervous trouble. Some of these qualities ought also to 
exist in mothers if they are to be allowed to nurse their 
own children. 

If for any reason a nurse is not wanted or cannot be 
obtained, the addition of natural milk fat to the milk, 
diluted as described above, furnishes a satisfactory method 
of increasing the nutritive value of the milk-and-water 
mixture without injuring its digestibility. Among prepa- 
rations of this kind we have Biedert's ^' Rahmgemenge" 
(cream mixture) and Soldner's '^ Eahmkonserve '' (con- 
densed or preserved cream — Loflund). 

The use of these preparations depends on a chemical compari- 
son between human milk and cows' milk, it being found that the 
chemical constitution, so far as we know, of cows' milk approaches 
that of human milk if Ij gr. (0.1 gm.) of nitrogen from albumin, 
If drachms (7 gm. cream fat), 6 drachms (25 gm.) of sugar of milk, 
and 8 fl. oz. (250 c.c.) of water are added to 8 fl. oz. (250 c.c.) of 
cows' milk — which contains 18i drachms (1.2 gm.) nitrogen from 
albumin, 2\ drachms (8.7 gm.) fat, 3 drachms (11 gm.) carbohy- 
drates, 2(3 gr. (1.7 gm.) ash. In practice such a mixture is obtained 
for a child fourteen days old, for instance, by mixing one-fourth 
of a quart (liter) of cows' milk w^ith 7 J fl. oz. (220 c.c.) of water, 
7 drachms (28 gm.) of *' Rahmkonserve," 3J drachms (14 gm.) 
milk-sugar, making in all 18 fl. oz. (530 c.c). 

The Subsequent Care of the Infant. — Im- 
mediately after birth the eyes are to be wiped clean. If 
there is any suspicion of gonorrhea, one to two drops of 
a 2 per cent, solution of argentic nitrate are to be in- 
stilled into the eyes and moist compresses put on. The 
navel readily becomes infected and the following direc- 
tions are therefore to be observed : 



HYGIENE AND 3IANAGEMENT OF PREGNANCY. 123 

1st. The nurse is to attend to the child first, and see 
that her liands and especially her finger-nails are clean. 

2d. The stump should dry as quickly as possible ; this 
process of mummification is assisted by dusting the stump 
with any desiccating and disinfecting powder (the author 
prefers nosophen and starch, or bismuth and starch, or 
powdered salicylic acid) and wrapping it loosely in salicyl- 
ated cotton. Ahlfeld suggests alcohol compresses. 

3d. The child is to be sponged twice daily, and not to 
be given a full bath until the cord has come away and 
the \vound is closed ; after that it may be bathed in water 
at the temperature of 95° F. (35° C). Many infants bear 
warm baths very badly. 

On the first day the proper evacuation of meconium 
and urine must be attended to. The child is to be fed 
every two or three hours, the first feeding to take place 
twelve hours after birth, either at the breast or with the 
bottle, the diaper being changed first. The mouth is to 
be wiped with a soft moist cloth before the child is fed. 
In the intervals between feeding the infant must not be 
disturbed. It ought to be part of the infant's education, 
as it is a sign of its good health, that it slee]) uninter- 
ruptedly from 10 or 11 o'clock at night till 5 o'clock 
in the morning, and this may be achieved by the end 
of the first month. The habit of carrying the baby 
about and singing it to sleep is a senseless maternal 
weakness and one that most nurses are unfornately ad- 
dicted to. The mother or nurse should never be allowed 
to take the child into bed with her, either because of lazi- 
ness or for the purpose of warming it, as it is a most 
dangerous practice. 

^ lo. HYGIENE AND MANAGEMENT OF PREGNANCY. 

The management of a pregnant woman has for its main 
objects the alleviation or prevention of certain physiolog- 
ical disturbances which are most apt to occur and are most 
marked in neurotic individuals, the preparation of the 



124 THE PUERPERIUM AND NEW-BORN INFANT. 

woman for the birth and subsequent feeding of her child, 
and, finally, the prevention of injuries which are liable to 
occur as pregnancy advances, or at the time of parturition, 
or during the puerperium. 

Above all, the physician should combat the idea that 
pregnancy is an abnormal condition and that the pregnant 
woman should be as careful of herself as if she were ill. 
On the other hand, she should avoid anything like 
dissipation and live a regular life. By this means we 
may hope to avoid any serious disturbances during preg- 
nancy, such as vomiting, constipation, or attacks of 
vertigo. The diet should consist of easily digestible and 
non-irritating foods that have no tendency to produce 
fermentation and flatulency ; alcoholic beverages should 
be avoided. The bowels must be regulated by appropriate 
vegetable diet and, if necessary, by the administration of 
enemata or even mild purgatives. The clothing should 
be loose and comfortable. Corsets should be avoided on 
account of the downward pressure which they exert ; they 
may be appropriately replaced by elastic corset-waists to 
which the underclothing can be buttoned. All pressure 
on the breasts must be avoided. If the abdominal walls 
are weak, binders should be worn during the second half 
of pregnancy to prevent the development of '^ pendulous 
abdomen. ^^ Mental depression is best avoided by appro- 
priate feminine duties and pursuits such as keep body 
and mind occupied, and furthermore by the assurance, 
based on accurate examination, that everything is in good 
order. The woman should be provided with sensible 
companionship and light and agreeable entertainment, all 
gossiping and recounting of horrible deliveries being 
strictly forbidden ; and, finally, she should be assured that 
all the necessary preparations for a proper delivery have 
been carefully attended to. If it seems advisable, admit- 
tance to a maternity hospital will contribute greatly to 
preserve the patient's peace of mind. 

In the care of the skin of the breasts and abdomen the 
most important point is a daily sponging with cool or 



SY3IPT0MAT0L0GY AND MANAGEMENT. 125 

tepid water. Hot baths I do not consider necessary except 
for the purpose of producing diaphoresis in cases of renal 
disease ; for purposes of cleanliness a full bath every 
week or every other week in addition to the daily spong- 
ing is quite sufficient. The last bath should be taken 
shortly before the onset of labor-pains. I do not recom- 
mend the use of astringent lotions on the nipples, but 
gentle manipulation is often necessary to draw out one 
that is imperfectly developed. Above all, cleanliness is 
to be enjoined. 

In the examination of a pregnant woman, which in- 
cludes a careful examination of the size and shape of the 
pelvis, the attention should be directed, above all, to the 
kidneys and to the heart, and, if either of these organs is 
found insufficient, energetic treatment is to be inaugurated 
at once. In chlorotic women it is not advisable to resort 
to forced feeding toward the end of pregnancy, as such a 
course rarely benefits the mother, w^hile it leads to exces- 
sive growth of the fetus which may seriously embarrass 
parturition. 

g II. SYMPTOMATOLOGY AND MANAGEMENT OF THE 

PUERPERIUM. 

The puerperium includes the involution of the genera- 
tive organs, the establishment of lactation, and the result- 
ing changes in the circulation and in metabolivsm. In 
civilized women rest in bed for from one to two weeks 
(in the dorsal position during the first twenty-four 
to twenty-eight hours) is necessary for the accomplish- 
ment of these changes. It cannot be denied, however, 
that strong, healthy women who are nursing their children 
are quite able to return to their ordinary occupations on 
the third or fourth day, and that the involution of the 
organs progresses even better under such circumstances, 
providing, always, that no infection has taken place. 
Kiistner made some experiments in this line in his clinic 
with very good results. Elasticity of the abdominal mus- 
cles, ligaments, and blood-vessels is a necessary prerequisite. 



126 THE PUERPERIUM AND NEW-BORN INFANT. 

First Day, Second Half. — Peptone and sugar are 
present in the urine, sometimes there is retention. Warm 
irrigation and compresses are useful ; the catheter should 
be used. Afterpains occur in multiparse. Diaphoretics 
should be given. The uterus is anteflexed and flattened 
from before backward, its length is appreciably dimin- 
ished ; the fundus is almost at the level of the umbilicus. 
Pulse from 40 to 70 ; bloody lochial discharges. 

Diet during the First Three Days. — Two cups 
of milk, one soft-boiled egg, a few zwieback, given in 
five meals. At night w^ater or milk. 

Second Day. — If the bladder is empty the fundus of the 
uterus stands about a hand's breadth above the symphysis. 
The dorsal position should be maintained until the third 
or the fifth day ; after that the woman should lie on her 
side, especially if there is any tendency to retroversion 
or retroflexion. The bladder must be emptied at least 
twice a day. After each evacuation ih^ vulva should be 
irrigated either with boiled water or w^ith 0.5 per cent, 
sublimate or 1 to 2 per cent, carbolic-acid solution or 
0.5 per cent, lysol solution, and wiped dry with cotton. 
If there are any excoriations or fissures about the vulva, 
or sutured perineal tears, they must be dusted with noso- 
phen powder (dermatol, iodoform, and so on) or covered 
with airol or zinc paste, after which a vulvar pad is placed 
on the labia. Diaphoresis should be encouraged. In 
multiparse lactation begins. 

In the infant's umbilicus the line of demarcation sepa- 
rating the mummifying umbilical cord appears, and is at- 
tended with slight exudation ; the cord is to be dusted 
with salicylic powder, or nosophen, or bismuth and starch 
powder and loosely wrapped in cotton ; the child is never 
to be completely immersed in the bath until the navel is 
entirely healed, so as to keep the cord dry. The child is 
fed for the first time twelve hours after birth, and its 
navel and eyes should always be attended to before the 
mother. 

Third Day. — The breasts have reached their highest 



SYMPTOMATOLOGY AND MANAGEMENT. 127 

degree of distention ; the fundus is a hand's breadth 
above the symphysis. Beginning of serous lochia, which 
are of a pale meat color and have a peculiar stale odor. 
If the lochia remain bloody for several days, and after- 
pains continue, it is a sign of endometritis. Under such 
conditions the discharges readily become fetid. Primiparse 
suffer less from afterpains and the bloody lochia last 
longer, because involution progresses more slowly. The 
phvsiological variation in temperature during these days 
is 'between 98.6° and 100.4° F. (37° and 38° C.) ; a 
temperature above 100.4°F. (38° C.) is to be regarded as 
febrile. Evacuation of the bowels must be carefully at- 
tended to. 

Fourth Day. — The fundus uteri, in other words, the 
highest point of the posterior wall, is midway between 
the symphysis and the umbilicus. The colostrum changes 
to thin, watery milk. Most abundant milk secretion ; 
diminution of the lochia. Greatest percentage of nitro- 
gen in the urine. 

The umbilical cord in the child separates, although some- 
times not until the sixth day. Up to this time the alvine 
discharges have consisted of meconium (the saline colostrum 
acts as a purge) ; from now on the stools are yellow, like 
saffron or yolk of e^^^ with very minute sediment ; if the 
child is fed on cow's milk the stools contain coarse, firm 
particles. Up to this time the bodv weight diminishes. 
Temperature— 98.4° to 100° F. (36.8° to 37.7° C.)— 
highest after nursing, that is, usually at noon. Physio- 
logical icterus most intense. From now on dailv full 
bath at 89.2° F. (31.7° C). Some children do not bear 
this very well, and must be washed daily in tepid water 
and given a full bath only once a week. 

Diet from the Fourth to the Sixth Day. — Three 
cups of milk (with a little coffee or tea), one plate of 
bouillon, two saucers of oatmeal or other cereal, one egg, 
a quarter of a pound of chopped white meat. Three 
times a day a zwieback or a roll, once a day some diges- 
tible preserves (apple). The above to be given in five 



128 THE PUERPEBIUM AND NEW-BORN INFANT. 

meals. At night sugar-water with lemon, or milk, pos- 
sibly a glass of good Burgundy, or broth. 

Eighth Day. — Lochia alba begin. The cervix usu- 
ally admits one finger and the placental site can be felt as 
a roughened area; the uterus is anteflexed ; the fundus 
three fingers' breadth above the symphysis. Colostrum 
corpuscles have disappeared from the milk. 

The child in one-half of the cases regains its original 
weight. The temperature becomes more stable. 

Ninth Day. — The fundus uteri or, if the anteflexion 
is marked, the highest point of the posterior wall is be- 
hind the symphysis. The external os begins to close; the 
vaginal portion of the cervix begins to project freely into 
the vagina. After this day the woman may get up if 
she wishes to. Great care is necessary to guard against 
attacks of syncope and embolism. 

Diet for the Seventh to the Twelfth Day.— Two 
cups of milk (with a little coffee or tea) or cocoa. Three 
times a day bread of some sort ; one e^gg. Twice a day 
rice, farina, oatmeal, whole oats, or, if desired, a little 
scraped raw meat, ham, or beef-steak ; a quarter of a pound 
of roast white meat once a day ; some digestible vegetable 
(rice or farina) ; preserves ; one plate of bouillon once a 
day ; broth ; possibly two glasses of Burgundy or lemon- 
ade. Give the above in five meals. At night, milk. 

Twelfth Day. — It is advisable for the woman to get 
up. She should not remain in bed any longer except for 
a special reason ; in weak individuals a longer rest in bed 
leads to general relaxation, especially of the pelvic organs. 
After the third week the uterus sinks below the pelvic 
brim. 

The child now gains weight at the average rate of f to 
1^ oz. (20 to 35 gm.) per day. It should be put to the 
breast every three (or two and one-half) hours or given 
2f to 31 fl. oz. (85 to 110 c.c.) of the milk-mixture, 3 : 1 
milk. It must now be accustomed to sleep through the 
night from 10 P. M. to 5 A. M. without any food. During 
the day it should be allowed to sleep as much as it pleases. 



SYMPTOMATOLOGY AND MANAGEMENT. 129 

Fourth to Sixth Week. — The involution of the 
uterus is completed. The lochial discharges cease. 
Anatomically the placental site is still visible as a marked 
prominence. 

At the end of the tirst month the child weighs on the 
average between 7| and 8J lb. (3.5 and 4 kilos), after six 
weeks, from 8| to 9J lb. (4 to 4.5 kilos). Milk-mixture, 
2 : 1 milk, 24 to 27 fl. oz. (700 to 800 c.c). 

Sixth to Eighth Week. — Return of menstruation 
in those women who are not nursing their children. In 
debilitated women or in those who are suffering from 
metritis this period is apt to be verv profuse. 

The child weighs from 9^ to 10^ lb. (4} to 4f kilos). 
Milk-mixture, 1 : 1 milk, 27 to 31 fl. oz. (800 to 900 c.c). 
Artificially fed children weigh a little less, but they 
usually make up this difference at the time when all 
children begin to take a mixed diet. 

During the third month the mixture should be 1 : 2 
milk, 31 to 34 fl. oz. (900 to 1000 c.c). After that, 1 : 3, 
and the proportion of milk gradually increased to 1 quart 
(1000 c.c). During the fifth or sixth month in many 
cases cows' milk can be given (1 quart = 1000 c.c roughly), 
after the eighth month, 2^ pints (1200 c.c) of milk. 

AVeaning, or, in the case of artificially fed children, 
the change to mixed diet, should be effected from the 
ninth to the twelfth month, depending chiefly on the time 
of the first dentition, which varies with the constitution. 
The diet should consist of 2\ pints (1200 c.c.) of milk, 
and in addition, eo^^^^ bouillon (the child may be al- 
lowed to suck pieces of meat), puree of meat, various 
kinds of soft food, spinach, apple-sauce, and orange-juice. 



I 



Table of Dextitiox. 
6th to 9tli ) . , -1, ^. - 1 1 • ^- ^ ., I by the end of 

5th to 7th f ^^^"^^' t^^ *^*^ ^^'^^^■^l ^^^^^ mcisors, | ^^^^^ g^^^ ^^^^. 
8th to 10th month, the two central upper incisors, \ all the in- 

12th to 15th month, the two lateral upper incisors, | cisors h ave 

11th to r2th month, the two lateral lower incisors, J erupted. 

14th to 16tli month, four bicuspids. 

18th to 20th month, four canines. 

22d to 26th month, four molars. 



130 THE PUERPERIUM AND NEW-BORN INFANT. 

The Child Weighs: 

End of 3d month, 10^ to 12 lb. (4S to 5i kilos). 

" 4th " 12 to 14i lb. (5i to Qh " 

" 5th " 13i to 141 lb. (6 to 6| " 

" 6th " 14i to 15.V lb. (6^ to 7 " 

" 7th " 15i to 173 lb. (7 to 8 " 

" 8th " 16 to 18i lb. (7^ to 8i " 

" 9th " 16J to 211 lb. (7§ to 85 " 

" 10th " 171 to 19J lb. (8 to 9 " 

" 12th " 194 to 20^ lb. (9 to 9^^ " 

Treatment of the Puerpera. — We have seen that 
the physiological object of the poerperium is in the first 
place the involution of the organs of gestation and of 
their supporting structures, among which we include the 
pelvic peritoneum and the abdominal walls, and further, 
the restoration of the organs of nutrition, respiration, cir- 
culation, and excretion, which all share more or less in 
the metabolic changes incident to pregnancy. The in- 
volution of the former is the slowest, and the length of 
time during which the woman remains in bed is there- 
fore determined by its progress : as long as the lochia! 
discharges contain blood or the uterus can be felt above 
the symphysis, the puerpera must remain in bed, otherwise 
there is danger of a chronic, persistent congestion predispos- 
ing to other inflammatory changes (metritis), or, on the 
other hand, of undue stretching and prolapse of the relaxed 
pelvic organs. Women who are predisposed to such an ac- 
cident should not be allowed to lie on their backs too long, 
because that position favors retroversion and retroflexion 
of the relaxed uterus. They should, therefore, be made 
to lie on their sides after the fourth day. On the other 
hand, women with vigorous and elastic tissues often lose 
less blood and experience earlier involution of the nterus 
if they get up after three or four days. If a woman has 
no fever and is not suffering from any kind of weakness, 
as from hemorrhage, she should not be allowed to remain 
in bed longer than twelve to fourteen days without a very 
strong reason, as in such a case the protracted rest in 
bed leads to undesirable relaxation of the body, mani- 
festing itself at first in sluggishness of the bowels. Loss 



SVMPTOJIATOLOGY AXI) MAXAGEMENT. 131 

of elasticity in the abdominal walls, or pendulous ab- 
domen, is often an accompaniment, although not a conse- 
quence, of this condition. To guard against it some 
form of binder is to be applied to the abdomen imme- 
diate! v after the woman is delivered (or a folded bed- 
sheet "mav l)e laid on the abdomen), and after the third 
day the bowels must be emptied regularlv, either by re- 
minding the puerpera to move her bowels or, if necessary, by 
the administration of enemata. The same attention should 
be Q:iven from the very beginning to evacuation of the 
bladder. The diet is to be regulated according to the above 
schedule. Milk is the best food, but one must guard 
ao-ainst over-feeding. If the abdomen is relaxed and if 
milk-secretion is insufficient, the abdomen should be mas- 
saged several times daily. 

The vulva as well as the perineal and gluteal regions are 
to be washed twice daily with warm water and soap, and 
irrigated with boiled water or a weak antiseptic solution, 
the nymphffi being held apart, especially if any fissures or 
excoriations are seen about the vaginal outlet. On the 
other hand, vaginal douches must be avoided after the 
placenta has been delivered, in fact, the inner portions of 
the sexual organs should not be touched after delivery of 
the placenta without a very strong reason. 

The second point that should engage our attention is 
the general condition of the puerpera, as it enables us to 
judge whether infection of the genitalia has taken place 
or not. Hence the temperature and pulse are to be taken 
everv morning and evening, the sensitiveness of the 
abdomen in ge'neral and of the uterus and adnexse in par- 
ticular, as well as of the mamma, is to be investigated, 
and, finallv, the color and odor of the lochial discharges 
should be* carefully noted. If fever makes its appear- 
ance (the relation between the pulse and the temperature 
is verv important in this connection in the beginning) 
without any other evident cause the origin of the trouble 
is to be sought in the genitalia. "Puerperal fever" 
under such conditions is ni almost every case a sign of 



132 THE PUERPERIUM AND NEW-BORN INFANT. 

genital infection. So-called milk-fever, in the ancient 
sense of the term, does not exist. In the relaxed condi- 
tion of the genitalia, especially in marked anteflexion of 
the uterus, a fever due to absorption sometimes makes its 
appearance on the third or fourth day and lasts from 
twenty-four to forty-eight hours. As soon as the first 
symptoms of distress, such as restlessness and insomnia, 
make their appearance, it is most important to induce 
thorough diaphoresis, defecation, and diuresis. 

The woman should avoid all sudden movements when 
she sits up or gets up out of bed, on account of the 
danger of pulmonary embolism from a thrombus at the 
placental site, especially after endometritis. Such an 
accident may lead to the gravest complications and has 
often resulted in sudden death. On the other hand, it is 
advisable to let the puerpera sit u}) under proper precau- 
tions during the first days, to prevent stagnation of the 
lochia in the vagina. 

Lactation next demands our attention. I liave already 
mentioned the desirable qualities in the motlier or nurse 
who is to suckle the baby, as well as the care demanded 
by the mammary glands and nipples during pregnancy. 
When the womarx begins to nurse, the nipples and the 
clothing with which they come in contact must be kept 
scrupulously clean to prevent the entrance of the Oidium 
albicans into the infant's mouth. The mother should lie 
on her side and hold the child in the liollow of her arm. 
Mother and child must never sleep in the same bed. 
This caution is to be strictly enforced in the case of 
nurses. If the nipples are unfit for sucking and there is 
still a plentiful supply of good milk, a false nipple should 
be used, either one of the old kind, made of rubber, or 
one made of glass. Auvard's is the best for weakly 
children, because it permits the mother to assist in draw- 
ing out the milk. All such apparatus must also be kept 
scrupulously clean. The breast is to be Avashed after 
every nursing. Weakly or premature children are to be 
fed with a spoon, which must also be kept clean. 



SYMPTOMATOLOGY AND MANAGEMENT. 133 

If milk secretion is insufficient, it can he increased by 
massage of the relaxed ahdomen and the application of a 
firm binder, supplemented with a weight applied on the 
abdomen, by the administration of somatose, and by be- 
ginning twelve hours after birth to put the child to the 
breast regularly. 

Menstruation, which occurs after six weeks in 45 per 
cent, and regularly in 20 per cent, of puerperal women, 
does not affect either the quantity or the quality of the 
milk, provided the milk secretion is good. Even the oc- 
currence of pregnancy exercises no injurious influence on 
lactation in healthy mothers, nor on the development of 
the fetus ; I saw a case in which a mother who did not 
know she was pregnant nursed her child during the 
first four months of pregnancy. The physician should 
therefore be guided in his advice by the constitution of 
the individual. Nursing need not necessarily be forbid- 
den after the occurrence of pregnancy. Pregnancy is 
most apt to occur when the menstrual period reappears 
regularly, that is to say, in 20 per cent, of all nursing 
women. If on account of inflammatory conditions or 
for any other reason the child has been weaned, and its 
nutrition is thereby very much reduced, it is possible to 
restore the milk secretion even after wTcks of inactivity 
by again putting the child to the breast. 



PART II. 

Pathology and Treatment of Preg- 
nancy, Labor, and the Puerperium. 



CHAPTER V. 



THE PATHOLOGY OF PREGNANCY, INCLUDING 
ABORTION AND PREMATURE LABOR. 

§ 12. ANOMALIES WHICH LEAD TO ABORTION. 

By abortion is meant the premature expulsion of the 
ovum before the formation of the placenta is completed ; 
that is to say, before the fourth month ; after that period 
we speak of premature birth. 

DIAGNOSIS AND TREATMENT OF ABORTION. 

The beginning of an abortion is diagnosed by the 
bright red color of the vulva and vaginal walls, the 
softening and enlargement of the uterus, especially in the 
anteroposterior diameter, giving it a balloon-like shape, 
and by the occurrence of persistent hemorrhage. In 
some cases there is a history of preceding amenorrhea. 

(a) If the external os is closed the treatment must be 
expectant. If the abortion is due to an accident, such as 
a fall, and not to constitutional disease, the prospect of 
bringing the embryo to maturity is good, especially in 
vigorous women, even without protracted rest in bed, as I 
can illustrate by the following case : 

134 



AXOMALIES WHICH LEAD TO ABOHTION. 135 

A hotcl-kcepcr changed her residence to another town at a time 
when without knowing it she was in her second month of preg- 
nancy. Before her departure she fell from the fifth rung of a ladder 
and immediately had a fairly copious hemorrhage from the geni- 
talia, which persisted during all the time she was engaged in 
packing and in making the journey and for three weeks afterward, 
at which time the woman slipped as she stepped out of the bath- 
tub and again fell to the floor. The hemorrhage became more 
profuse and slight pains resembling labor-pains made their ap- 
pearance. When I told her my diagnosis she was very much 
astonished to learn that she was pregnant. She would not hear 
of going to bed, partly because she was not quite convinced of her 
pregnancy and partly on account of the duties demanded of her 
by her business. I administered opiates per vaginam and went 
away expecting to be called again. I was not sent for again, 
however, until I was called in to deliver a healthy and well- 
developed boy at term. The placenta showed no changes. I had 
convinced myself at the time by an examination with the specu- 
lum that the hemorrhage came from the uterus. 

Expectant treatment consists in ordering the patient to 
bed for a period not longer than eight days, and in admin- 
istering opiates in bougies, or vaginal douches of tepid 
boiled water with the least possible amount of pressure. 
If the hemorrhage is profuse and persistent, cold irriga- 
tions should be given and compresses applied to the 
abdomen. As a matter of course, strict antiseptic pre- 
cautions mnst be observed in making explorations or 
other manipulations so as to minimize the danger of 
infection. 

(6) If the external os is dilated and the tip of the ovum 
projects into the cervical canal, we have to deal with an 
advanced abortion which cannot be averted. In such a 
case removal of the ovum is indicated, it being immaterial 
whether the hemorrhage is profuse, as is usually the case, 
or slight (for technique see Atlas of Labor and Operative 
Obstetrics). The cervical canal and vagina are packed 
with tampons of sterilized gauze (iodoform or nosophen) ; 
and ero^ot, ergotin, or quinine sulphate (several doses of 
gr. viij =0.5 gm.) are giveu by the mouth. If the labor- 
pains are strong, tampon and ovum are expelled from the 
uterus. If, on the other hand, labor-pains cease, the ovum 



136 THE PATHOLOGY OF PREGNANCY. 

is found behind the tampon and can be easily removed 
with the abortion foi'ceps. Complete expulsion of the 
uninjured ovum is not to be expected, as a rule, after 
the fourth month. Later than that the amniotic sac first 
ruptures ; this is followed by the appearance of the fetus, 
and finally the placenta comes away. 

(c) If the product of conception has already been ex- 
pelled, the cervical canal is found dilated, the body of the 
uterus is usually hard and contracted by the severe labor- 
pains, although it may continue to bleed in spite of the 
pains, and the hemorrhage will certainly recur as soon as 
the contractions cease. Digital exploration reveals a rough 
surface with blood-clots and epithelial shreds, which under 
the microscope are seen to consist of chorionic villi and 
decidual tissue (see Figs. 15 and 16). 

If portions of the membranes remain behind, the hemor- 
rhage persists, the blood being mixed with brownish 
particles, which eventually give off a fetid odor. Under 
these conditions, whether we have to deal with a fresh case 
accompanied by profuse hemorrhages, or septic infection 
has occurred from the remains of the fetal membranes, 
the uterus is to be evacuated by means of bimanual com- 
pression, or it may be rapidly dilated by means of conical 
metal dilators of various sizes, after Fritsch and Hegar. 
If expression fails to remove the placental remains, the 
interior of the uterus must be scraped with two fingers or 
with a blunt curette (see Atlas of Labor and Operative 
Obstetrics). 

In cases of putrid abortion the author recommends 
vaporization, but not before the length of the uterus has 
been accurately determined, and only with a heated in- 
strument — that is to say, not directly w^ith steam — and 
only when it is performed by a practised hand. These 
procedures are to be followed by irrigation with 2 per 
cent, solution of carbolic acid, packing of the uterus with 
iodoform gauze for twenty-four hours, the administration 
of ergotin, and rest in bed for a week. If there is fever, 
Priessnitz compresses and mild laxatives are indicated. 



ANOMALIES WHICH LEAD TO ABORTION. 137 

If it is impossible to arrest the septic process, total extir- 
pation of the organ may have to be considered. 

If portions of the membranes remain within the uterus, 
they tend to keep up the hemorrhage, and the constant 
deposition of fibrin may lead to their organization, so that 
the entire uterine cavity may be filled with a plastic 
material. This process may take place if portions of the 
placenta remain after the expulsion of an older, or even 
of a mature, ovum. Such partial retention of the placenta 
leads to what is known as "a placental polyp. If an 
ovum is expelled or removed in toto, the uterus need not 
be curetted, as any remaining portions of the decidua do 
not in the least interfere with the regeneration of the 
mucous membrane. Tamponade is required only after 
hemorrhages, or after curettage of the uterus performed 
for the purpose of removing larger adherent portions of 
the membrane. If the temperature rises, the tampon is 
to be at once removed. The mechanism of the separation 
of an aborted ovum is the same as that of an older 
placenta (see Fig. 11 in the text). A retroplacental he- 
matoma forms usually at the edge of the insertion of the 
ovum in the decidua vera, and separation begins either at 
the margin or at the central portion of the insertion. In 
the former case a part of the ovum nearest the true mater- 
nal area of separation first appears in the cervical canal. 
In the latter case the villous decidua reflexa is the first to 
appear. If in the latter mode of separation the fetal 
membranes rupture, the ovum is, of course, expelled first, 
and the free portions of the fetal membranes become 
wrapped about the massive portion of the ovum toward 
the fundus; in other words, the fetal surface of the 
amniotic sac prolapses. 

If the embryo is retained in the uterine cavity, it be- 
comes macerated and then undergoes absorption. The 
fetus may undergo mummification (fetus papyraceus), but 
on the admittance of air or pathogenic organisms putrefac- 
tion takes place. Thus the fetus may be retained in utero 



138 THE PATHOLOGY OF PREGNANCY. 

beyond the physiological duration of pregnancy (missed 
abortion). 

Lithopedia, which are sometimes found in the uterus, 
are probably derived from tubal or other extra-uterine 
pregnancies, or from amniotic sacs within rudimentary 
cornua. 

The treatment does not, as a rule, end with the removal 
of the ovum, because the causes of abortion, which are 
too often regarded as its consequences, still persist. As 
a rule, they consist in inflammatory conditions of the mater- 
nal or fetal membranes, or in general constitutional diseases 
such as syphilis or perhaps tuberculosis, which find their 
local expression at this point, or in acute febrile infectious 
diseases or in excessive physical or mental excitement 
(circulatory disturbances), or, finally, in displacements and 
tumors in the various portions of the genital tract. 

Accordingly, we observe after an abortion persistence 
of the congestion and chronic inflammations, catarrhal 
hypersecretion, menorrhagia, displacements of the uterus, 
either by a flexion of the imperfectly involuted walls or 
by adhesions. 

One abortion predisposes to others, hence in a succeeding preg- 
nancy preventive measures are indicated. One of my patients 
had four abortions folh)wing four normal pregnancies. In the 
fourth month of her ninth pregnancy I found a perineal tear of 
the second degree, inversion of the interior vaginal wall w^ith a 
cystocele, and a deep ulceration of the external os with marked 
ectropion of the cervical mucous membrane. I applied a Mayer 
ring-pessary and pregnancy went on to term, although hemorrhages 
had already occurred. 

In another case in which there were hemorrhages in the sixth 
month of pregnancy, the woman having previously had an abor- 
tion, the hemorrhages were controlled by invigorating measures 
(iron, massage) and by the use of vaginal irrigations with luke- 
warm emollient solutions. 

The morbid anatomy of the aborted ovum varies with 
the cause of its expulsion. 

(1) Sub chorionic, that is to say, decidual hemorrhages, 
are apt to form in general infectious diseases, especially 
acute diseases attended with high temperature (typhus. 



ANOMALIES WHICH LEAD TO ABORTION. 139 

cholera, variola, influenza), and, by interfering with the 
circulation and possibly by the transmission of toxins, 
bring about the death of tlie fetus. Direct infection, on 
the other hand, by the transmission of pathogenic micro- 
organisms to the fetus, which has been proven experi- 
mentally and clinically (pockmarks in the new-born 
infant), may be survived. 

These hemorrhages into the decidua (most frequently into the 
serotina) are found either in the stroma, when' thev force the 
fibers and large decidual cells apart, or in the gland-follicles, or 
in preformed invaginations of the fetal membranes which continue 
to grow after the death of the fetus— the so-called hematoma 
moles described by Breus. They produce nodes the size of a 
hazelnut in the fetal membranes, and these, in addition to infect- 
ing the fetus, may lead to malformations bv their interference 
with the fetal movements (Figs. 88, 91, and 92; Fig. 11 in the 
text). 

These hemorrhages usually bring on an abortion before 
the fourth month. As a rule, the embryo undergoes ab- 
sorption — the amniotic fluid is turbid and brownish in 
color, remains of the umbilical cord and of the allantoid 
ve-icle are seen — or the fetus dies as the result of torsion 
of the cord and undergoes maceration. The ovum may 
continue to grow by itself. 

In other cases a lymphoid exudation separates the 
amnion, and the ovum may be expelled either in its own 
fetal membranes, that is, the chorion and amnion, or in 
the intact amniotic sac alone (Fig. 12 in the text). Ex- 
pulsion with the maternal decidua, that is, with a com- 
plete cast of the uterine body in the form of detached 
decidua vera, is illustrated in Figs. 67, a, and 67, 6 ; we 
see that the ovum in the first and second month is smaller 
than the uterine cavity (Figs. 17 and 18), showing that 
the latter is growing actively. 

Cf. Fig. 67, a. DHangular Piece of Decidua Vera Expelled in an 
Extra-uterine Pregnancy. — The external surface is rough, the in- 
ternal surface shows the mouths of ducts and numerous plications. 

Fig. 67, b. The Same. — In this case the decidua vera has formed 
below the internal os in an expanded portion of the cervix, an 



140 THE PATHOLOGY OF PREGNANCY. 

Plate 36. 

Fig. 81. Necrotic Decidua of a Hematoma Mole Retained in utero, 
so-called missed abortion (original water-color, natural size, from the 
author's own case). 

Plate 38. 

Fig. 88. Mummified Fetus with Retained Abortive Ovum (belonging 
to Fig. 81). — The ovum grew with the fetus until the third month, after 
which time amenorrhea continued ten months longer. Thus, after an 
interval of thirteen months, the menstrual flow reappeared with great 
pain, portions of the necrotic decidua serotina being discharged at each 
period. The ovum itself, however, was retained two months longer, 
when it was finally expelled with labor-pains and a moderately copious 
menstrual flow. The decidua (Fig. 81) was also necrotic. The rest was 
filled with coagulated hematomata. so that the chorion bulged into the 
amniotic sac (Fig. 88). Hematomata are also seen on the maternal sur- 
face. The amniotic sac is filled with dry masses of clotted blood, the 
remains of which can be seen in the illustration as reddish nodules 
covering the irregular amnion and depriving it of its luster. The 
amniotic fluid was entirely absorbed. The fetus measured about 3J in. 
(8 cm.) in length, was much deformed, and showed signs of an inflam- 
matory process which had evidently made its appearance late. The left 
foot had grown fast to the right leg. 

In the Munich Gynecological Clinic there is a fetus which presents 
similar abnormalities. In this case the umbilical cord passes through 
the femoral ring, a proof of the late development of the condition. The 
right eye and the nose were covered over with membranous bands, the 
flngers and toes were grown together, the body was mummified, the 
umbilical cord twisted, the torsion being greatest at the abdominal ex- 
tremity. Missed abortion takes place when the fetus and chorion grad- 
ually die, as in chronic disease of both parents. 

Plate 39. 

Fig. 89. Hydatid Mole (original water-color). — Some normal placental 
tissue is seen between the cystic myxomatous chorionic villi on the ex- 
ternal surface. The color of the surface of the villi corresponds to their 
degree of vascularization. A few of the cysts are attached to pedicles 
formed of chorionic villi. A large percentage of the placenta was normal 
and had sufficed for the nutrition of a well-formed fetus which was born 
prematurely. The free membranes and the amniotic cavity show noth- 
ing abnormal. 

exceptional condition of affairs. (Both original drawings after 
preparations at the Munich Gynecological Clinic.) 

After the fifth month the amniotic fluid is, as a rule, 



Tab. 39. 



^r^^bw 




^ 



Fig. 89 



,rhh,.lil Mrinrh, 



ANOMALIES WHICH LEAD TO ABORTION. 141 



discharged before the expulsion of the ovum takes place ; 
hence a perfectly preserved ovum from this period on is 
very rare. In Plate 5, Fig. 12, a three-months' ovum is 




D.V 



yi.RI-BN. 



ChJianf. 



Am.. 



CH 









^~ Nab. 


\% 




in 

i 




^ 


'1 
1 


1 


t 

1 




■ 1 ; 


, " j- 


6 


■^ij 



Fig. 11.— Beginning abortion after subchorionic decidual hemorrhage 
{Ch. Ham.), partly seen through the amniotic sac (Am.) and partly cut 
through. The largest hemorrhage is in thedecidua vera {R. Ham.), and 
represents a kind of retroplacental hematoma, which increases as the 
ovum separates. The umbilical cord (Nab.) of the fetus is twisted, its 
insertion corresponds with the blood-clot, and thus leads to circulatory 
and respiratory disturbances which result in excessive twisting of the 
cord. The decidua vera (D. v.) extends to the internal os. 

seen artificially opened ; the decidua reflexa is torn into 
shreds and can easily be distinguished from the chorion 
(see also Fig. 8). In Fig. 13 is seen a completely de- 



142 THE PATHOLOGY OF PREGNANCY. 

Plate 40. 

Fig. 90. Decidual Endometritis (original drawing) : 1, dilated gland- 
follicles with desquamated epithelium; in hypersecretion these glands 
discharge their contents (as shown in numerals 9 and 10) between the 
decidua reflexa and the decidua vera into the free lumen of the uterus — 
hydrorrhea gravidarum ; 2, chorionic villi embedded in partially disinte- 
grated decidual tissue (3) ; 4, intact chorionic villi lying in the free 
intervillous spaces (filled with maternal serum or blood), either in close 
apposition or adherent to the decidua vera; 5, small vascular villi 
branching from a large attachment-villus (6), the latter gradually 
merges into decidual tissue ; 7, capillary vessels in the inflamed inter- 
stitial portion (3 and 9) very much dilated (not so much as a result of 
the inflammation as of pregnancy) ; 8, glandular endometritis ; 9, inter- 
stitial endometritis with areas of round-celled and leukocytic infiltra- 
tion ; 10, decidua reflexa merging into decidua vera ; 11, a gland with 
intact cylindrical epithelium from that part of the uterine cavity which 
is not filled with the ovum, although forming a part of the decidua 
vera ; 12, hypertrophied decidual tissue forming polypoid or bridge-like 
excrescences, and showing a telangiectactic tendency (7). (For the 
chorionic villi, cf. Figs. 16 and 91.) 

Plate 41. 

Fig. 91. Subchorionic, that is, Decidual Hemorrhage (original draw- 
ing from the author's own microscopical preparation) ; 1, papilla of 
decidua vera ; 2, extravasation in the decidual tissue, forcing the fibers 
of the stroma apart at 3; 4, thrombus of the intervillous space with 
normal chorionic villi (5) lying in juxtaposition with the decidua vera. 
According to the latest investigations the chorionic villi are not covered 
with cuboidal epithelium as was formerly supposed, but with a layer of 
protoplasm through which nuclei are scattered. 

Plate 41. 

Fig. 92. Subamniotic so-called "Fibrin," witli Cysts and Extrav- 
asation (original drawing from the author's own microscopical prepa- 
ration) : 1, single layer of cuboidal amniotic epithelium; 2, connective 
tissue; 3, so-called chorion cells, partly degenerated and converted into 
fibrin-like masses with parallel fibers as the efl'ect of amniotic and intra- 
uterine pressure (4) ; 0, homogeneous masses consisting of necrotic villi ; 
6, serous cysts Mnthout any protoplasmic investment (8), sanguineous 
cysts (6 and 8) lying within the degenerated masses of cells ; 7, accumu- 
lations of round cells ; 9, intervillous thrombus in the neighborhood of 
the necrotic villi (11), which have run together by necrosis of their 
protoplasmic covering (12) ; 10, normal vascular villi ; 13, decidual 
papilla with large capillary blood space (14) and gland (15). 



Tab. 40. 




Fig. 90. 



LiJth. Arist E ReidUwld, Mdndien. 



Tab. 41. 



-/ — iamv!^^'^"'<i*i'imt,t^ 





















Fig. 91. 



^1 <^f--£i^->^-«,;-^^<- 










Fig. 92. 



Z«yi. ^«.5? F. Rachhold, Miindien. 



ANOMALIES WHICH LEAD TO ABORTION. 143 



veloped placenta serotina and the torn chorionic mem- 
brane, which has undergone invokition and has become 
united with the decidua reflexa, and finally, the amnion 
of a four-months' ovum. In rare instances the fetus may 




Fig. 12. — Intact amniotic sac {Am.) expelled in the premature delivery 
of a seven-months' fetus. Above we see a fragment of detached chorion 
{Ch.), to the left the insertion of the cord {Nab.) where it has been torn 
away from the serotina. In most cases a fetus of this kind shows path- 
ological changes of some duration (original drawing from a preparation 
at the Munich Gynecological Clinic). 

be expelled with the amniotic sac intact, the latter sepa- 
rating from the chorion, and the umbilical cord becoming 
severed from the chorionic membrane (Fig. 12 in the 
text). 

The term blood-moles is applied to retained decidua 



144 THE PATHOLOGY OF PREGNANCY. 

when it becomes hemorrhagic and is subsequently expelled 
separately. 

Special pathological forms of abortion are produced 
either by inflammations of the endometrium or by general 
diseases, such as syphilis and eclampsia. 

Two kinds of inflammation of the uterine mucosa are distin- 
guished, that of the glandular portion and that of the connective- 
tissue stroma, termed, respectively, endometritis glandularis and 
interstitialis. The etiology of the two varieties is the same. Both 
may arise from chronic hyperemia, that is to say, from circulatory 
disturbances of a non-infectious origin or from infection (gonorrhea- 
tuberculosis, sepsis). 

Such forms of endometritis, though comparatively fre- 
quent, rarely lead to abortion or any special alteration of 
the fetal membranes ; but the inflammatory process is 
certainly not relieved by pregnancy. 

In rare cases it has been possible to demonstrate intercellular 
diplococci or bacteria in the fetal membranes. At the same time 
numerous foci of round-celled infiltrations surrounded by extensive 
hemorrhages were found in the decidua vera. The products of 
inflammation were also seen in the decidua serotina near the sur- 
face, in the form of aggregations of round-celled infiltration with 
a central necrotic area. 

Another variety of fetal disease due to endometritis 
catarrhalis deciduce verce is known symptomatically as 

(2) Hydrorrhoea uteri gravidi, and in this simple form 
rarely leads to abortion. As a result of hypersecretion 
of the hypertrophied and hyperplastic glands the decidua 
reflexa separates from the decidua vera and the secretion, 
which may exceed 3 fl. oz. (100 gm.) at each evacuation, 
is discharged from the internal os by uterine contrac- 
tions resembling labor-pains. It is distinguished from 
the amniotic fluid by the fact that it is not followed by 
premature birth and does not contain either vernix caseosa 
or lanugo hairs. From urine it is distinguished by the 
fact that it contains no urea or only very minute quanti- 
ties, that it is neutral or alkaline in reaction, and, finally, 
by the fact that it evidently emanates directly from the 



ANOMALIES WHICH LEAD TO ABORTION. 145 

uterus. It is distinguished from the secretion of a sim- 
ple cervical endometritis and colpitis by the fact that the 
latter is very much less in quantity and contains pus- 
corpuscles and fungi, whereas the secretion of hydrorrhea 
uteri gravidi is of a watery and glairy nature (rarely 
containing a small amount of blood or pus when combined 
Avith cervical endometritis), free from albumin, contains a 
large percentage of NaCl, carries a number of epithelial 
elements along with it, and has a specific gravity of 1003. 
The secretion collects between the two deciduse, or, 
owing to the permeability of the fetal membranes for 
amniotic fluid, may be found between the decidua reflexa 
and the chorion, or between the latter and the amnion. 
If the secretion is retained within the gland-spaces the 
condition is known as endometritis decidualis cystica 
(Fig. 90) ; if the inflamed and hyper23lastic mucosa un- 
dergoes proliferation a third pathological condition of the 
ovum is produced, known as 

(3) Decidua Polyposa. — Proliferation of the stroma and 
of the cellular elements progresses pari passu, and leads 
to the formation of polypoid excrescences consisting of 
fibrous tissue harboring large deciduous cells, which in- 
duce circulatory disturbances in the form of engorgement 
of individual dilated vessels and of the cavernous blood 
spaces (see Fig. 90, ^o. 12). Later copious extravasa- 
tions form, of which the polypoid excrescences ultimately 
appear to consist. 

On the other hand, there may be a defective formation 
of decidua vera, an atrophy, in other words, cell pro- 
liferation being absent and the newly formed cells un- 
dergoing fatty degeneration. The atrophic decidua is 
smooth. 

3Iyxoma ckorii multiplex is a nutritive disturbance of 
the chorionic villi, which in some cases appears to originate 
in the decidual elements — formerly it was attributed ex- 
clusively to the fetal tissues of the chorionic villi — this 
condition leads to the formation of 

(4) Hydatid moles (Fig. 89). 

10 



146 THE PATHOLOGY OF PREGNANCY. 

The histolopcal changes consist in proliferation of the syncyt- 
ium and secretion of mucus in the connective tissue of the villi, 
which become edematous and undergo myxomatous change. The 
connective tissue with its contained vessels eventually degenerates. 
Sometimes Langhans' layer proliferates. During the later 
months the decidua is destroyed, and in malignant cases the 
proliferated syncytium invades the muscular layer and the blood- 
vessels of the uterus. 

The condition may also be due to local inflammations 
of the endometrium or perhaps to infectious diseases on the 
part of the mother, or to disease of the ovum derived from 
the father ; abortion usually results. Sometimes the mole 
remains either wholly or in part within the uterine wall 
after expulsion of the ovum, undergoes further develop- 
ment, and takes the form of destructive myxoma, reach- 
ing the pampiniform plexus and sending metastatic 
emboli as far as the pulmonary artery. In other words, 
these hydatid moles behave like malignant tumors. 

Infective emboli from a hydatid mole retained in 
utero, as, for instance, the malignant bleeding nodules in 
the vagina in Schauta's case, are very rare, but their 
recognition is of great importance. In the case men- 
tioned, the attending physician had treated the patient 
for varix. In some cases the nature of the mole itself 
indicates the prognosis : the more the syncytium betw^een 
the individual cysts is degenerated the better the outlook, 
and the stronger the proliferation, the more malignant the 
process. 

The destructive process begins in the syncytium and the pro- 
liferation is, therefore, to be regarded as an epifhelioma of the 
chorion (Marchand). There is a group of cases, however, which 
present a sarcomatous character, and these should be designated 
as malignant deciduomata (Sanger) or as sarcoma deciduocellulare, 
depending on the preponderance of the chorionic or of the de- 
cidual tissues. 

Accordingly, active therapeutic measures are indicated. 
Abortion should be induced as rapidly as possible by ex- 
citing and keeping up the labor-pains, whether there is 
any hemorrhage or not — by tamponage, dilatation of the 



ANOMALIES WHICH LEAD TO ABORTION. 147 

cervix, evacuation of the uterus with the hand or with a 
blunt curette. The latter requires caution on account of 
the friable condition of the w^alls. 

The diagnosis is based on the appearance of a thin 
bloody discharge in the first months, and on the appear- 
ance, toward the middle of pregnancy, of uterine con- 
tractions and frequent hemorrhages. On examination the 
uterus is found to be undergoing rapid growth while 
remaining unusually soft, and without the appearance of 
any fetal parts during the second half of pregnancy. 

Once abortion has begun, the appearance of the char- 
acteristic cysts (Fig. 89) is an indication to effect the com- 
plete evacuation of the uterine cavity. 

After the abortion has terminated the patient must 
continue under medical supervision for months. Repeated 
irregular and copious hemorrhages point to a malignant 
character of the hydatid mole. In such a case the uterus 
should be curetted for the purpose of examination, and 
if the result is positive, immediate extirpation of the 
uterus is indicated, but without any further curettage. 
The tissue consists of a mixture of structureless syncytium 
containing large nuclei, giant-cells, and insular accumu- 
lations of smaller, less intensely staining ectodermal cells 
derived from Langhans' layer. 

Just as the myxoma may involve only a part of the 
placenta, so we may have a general or circumscribed 
gelatinous hyperplasia of the umbilical cord, resulting in 
the so-called edematous form of hydatid. Sometimes the 
increase in the amniotic fluid leads to another anomaly of 
the ovum, known as 

(5) Polyhydramnion, w^hieh does not in itself cause 
abortion, but may interrupt pregnancy, especially a 
double pregnancy, between the fifth and seventh months. 

Hydramnion is observed particularly in multiparse and 
with chronic diseases of the mother (syphilis, chronic 
anemia and relaxed condition of the system, leukemia and 
diabetes), but cannot in every case be referred to any 
definite symptoms of the mother, placenta, or child, 



148 THE PATHOLOGY OF PREGNANCY. 

although it may occur in combination with such symp- 
toms. Sometimes the process runs an acute course and 
threatens the life of the fetus. Acute onset has been ob- 
served after traumatism. 

In most cases polyhydramnion goes hand-in-hand with 
diseases of the fetus, such as edema, ascites, and anasarca 
in syphilis, and in hydrocephalic or transudative proc- 
esses the result of venous stasis, resulting either in hyper- 
secretion of the kidneys or in stasis of the umbilical 
veins and transudation through the amniotic lymphatic 
system into the amniotic sac. Hence hydramnion may 
be due to velamentous insertion of the cord, and some- 
times may accompany ectopic gestation. Finally, it may 
be produced by inflammatory processes in the fetus (syph- 
ilis in a few cases certainly), directly as an inflammatory 
exudate, indirectly as the result of stasis due to cirrhosis 
of the liver, phlebitis, and so on. The presence of a 
lymphagogue substance has been experimentally proven 
in a diseased ovum (Opitz). The author has seen two 
cases of twin pregnancy with acute hydramnion in which 
the fathers suffered with latent gonorrhea and infected 
their young wives ; later epididymitis developed, and 
although the microscopical examination of the semen 
showed it to be apparently healthy, the marriages con- 
tinued sterile. The women showed no further patholog- 
ical changes. 

Owing to the unequal division of the placental vascular 
system in twins (Schatz), the nutrition is unequal, and the 
resistance to the current varies in the so-called third pla- 
cental circulation which unites the two others. Hence 
poly- and oligohydramnion (Fig. 100), and in triplets, 
for instance, hydramnion of two amniotic sacs may 
occur. 

The diagnosis finds some assistance in the marked 
spherical shape of the uterus with unusual distention of 
the abdomen (see Fig. 127, showing excessive distention 
of the abdomen in the fifth month of pregnancy), out of 
all proportion to the duration of pregnancy, so that often 



ANOMALIES WHICH LEAD TO ABORTION. 149 

as early as the fifth or sixth month the pressure may in- 
terfere with respiration. The fetal parts are difficult to 
palpate, especially as the fetus is usually underdeveloped. 
It is a remarkable fact that in spite of the tension in the 
uterine cavity the presenting portion of the amniotic sac 
is relaxed. 

Treatment. — If the subjective symptoms become very 
marked and dyspnea sets in, puncture of the amniotic 
sac throuo^h the internal os is indicated — never throuo^h 
the abdominal walls. This procedure may be repeated, 
and is not by any means always followed by premature 
delivery. In some cases nature herself brings about re- 
lief in this way. 

Inflammations affecting all the structural parts of the 
placenta may be diffuse or circumscribed. 

(6) This inflammation of the placenta evidently derives 
its origin from infectious germs of various kinds, the 
development of which is exceedingly slow. Syphilis ini- 
doubtedly plays a part in the etiology, although it may 
not be possible to demonstrate it in every case. The con- 
dition known as eclampsia, which manifests itself in clonic 
convulsions attended with loss of consciousness, leads to 
analogous changes in the placenta, especially to the so- 
called placental infarcts which occur very frequently, but 
cannot in any sense be regarded as pathognomonic of 
eclampsia. A placental infarct consists in subamniotic 
necrotic foci which, on account of their lamellar structure, 
have been designated " subamniotic fibrin. '^ They often 
occur in combination with subamniotic serous or sanguin- 
eous cysts. 

Syphilis leads to inflammatory proliferation of the stroma 
and protoplasmic covering of the villi, with thickening 
of the walls of the blood-vessels contained in them and 
in the umbilical cord, which eventually becomes obliter- 
ated. 

These conditions tend to interfere w'ith the circulation 
of the fetus by necrotic separation of large portions of the 
placenta, by the formation of individual thrombi in the 



150 THE PATHOLOGY OF PREGNANCY. 

Fig. 93. Syphilitic Inflammatory Villi ; marked prolifevatiou of the 
connective-tissue and round-cell infiltration (5), especially in the 
neighborhood of the thickened blood-vessels (1). A few of the villi 
have lost their protoplasmic investment and are in process of conversion 
into intervillous thrombi (3) ; 6, normal protoplasm containing nuclei 
(cf. in this respect my remarks on Fig. 16) ; 7, villous blood-vessels — 
healthy, belonging to the fetus— (original microscopical drawing). 

Fig. 94. Transverse Section of a Syphilitic Umbilical Cord with In- 
flammation of the Media and Adventitia. — Eound-cell infiltration con- 
taining a central focus of softening (3) ; the other thickened arteiy (2) 
shows the characteristic triangular stellate form of the intima, the thick 
elastic fibers of the media, and the broad adventitia. The vein (1) has 
thin walls and gapes widely. The stroma is formed by normal myxo- 
matous connective tissue (4). Externally the umbilical cord is invested 
with amnion, that is to say, with a layer of cuboidal cells, 5 (original 
microscopical drawing). 

Fig. 95. Microscopical Image of a "Placental Infarct " (original draw- 
ing after a series of the author's own preparation, representing the 
histological development of such foci) : 1, decidua papillee in the chori- 
onic placenta ; 2, a robust connective-tissue villus in the decidual tissue 
conveying fetal blood-vessels; 3, normal villi containing fetal blood- 
vessels within the intervillous spaces, normally filled with maternal 
blood; here we plainly see the protoplasmic covering with nuclei scat- 
tered through it; 4, decidual cells separated from each other by exuda- 
tion and undergoing necrosis; 5, necrotic villi lying in degenerated 
decidual papillse, which have become converted into laminated masses 
of fibrous tissue (these layers [6] are the result of the varying pressure 
of the uterus on the ovum) ; 7, degenerated chorionic villi still retaining 
a trace of nuclear stain in the nuclei of the spindle-cells fused together 
by homogeneous masses of cell debris, formed by the fusion of the ne- 
crotic nucleated protoplasmic covering of the villi with secondary inter- 
villous thrombi ; 8, the necrotic cellular debris is undergoing organization ; 
9, a broad zone of connective tissue rich in cells is then formed ; 10, 
fibrinous intervillous thrombus ; 11, intervillous thrombus which has not 
yet undergone coagulation ; 12, villus in the first stage of necrobiotic 
homogeneous coloration of the pi'otoplasmic covering. The connective- 
tissue stroma of the villus is intact; 13, villus in the second stage of 
degeneration ; the covering is changed to a feebly staining, homogeneous, 
granular mass of debris, which becomes fused with that of the adjoining 
villus; the walls of the blood-vessels are thickened in places where the 
stroma of the villi begins to degenerate; 14, calcareous deposits; 15, 
minute cysts within the berry-like proliferations of the protoplasmic 
covering (16), wiiich at this point is peculiarly rich in cells ; 17, deposits 
of calcified material within these cysts. 

maternal blood spaces, or by diminution of the fetal pla- 



Tab. 42. 




Fig. 94. 



Lith..Ansi E ReichJwld, Mu/idim. 



CO 
08 

H 



3^ 



^ ^ ^ 










ANOMALIES WHICH LEAD TO ABORTION. 151 

cental circulation. In addition to this the condition 
proiluces active fetal movements, as a result of which, or 
of the stasis and pressure during the first third of fetal 
life when the heart is still pulsating, we have twisting of 
the umbilical cord (most marked at the navel, Figs. 88 and 
100), or the formation of coils about the trunk, neck, and 
extremities and true knotting of the cord, all which condi- 
tions in turn lead to interference with the fetal blood 
circulation. 

A woman is very liable to syphilitic infection at the 
time of conception or during pregnancy. The more recent 
the syphilitic infection in the father or in both parents 
(the father may infect the fetus without infecting the 
mother), the more likely is abortion to result. From the 
time of infection until four weeks before birth premature 
delivery rarely takes })lace ; on the other hand, however, 
infection of the infant is common. If the fetus does not 
die in utero and undergo maceration, the symjDtoms may 
be very slight : malnutrition, insufficient increase in weight 
from the very beginning, and gradual decline during the 
first year of life ; the characteristic pemphigoid eruption 
on the soles of the feet and palms of the hands ; the len- 
ticular roseola syphilitica; the nodular form of lichen ; 
rliagades about the various orifices of the body ; ecthyma 
pustules (containing pus) ; dropsy of peripheral portions 
and of the skin and often ascites and hydrothorax, in- 
cluding a large number of cases of hydrocephalus which 
can now with certainty be included in this category ; 
osteochondritis at the boundary between the epiphyses and 
diaphyses, especially of the tibia and femur; hepatic 
enlargement from overgrowth of connective tissue, gastric 
ulcers (forming a part of the cases of melaena neonatorum), 
and interstitial pneumonia (asphyxia). 

The syphilitic poison may pass through the mother to 
the placenta and thence to the fetus, but such a mode of 
transmission is rare. In the great majority of cases the 
infection of the ovum dates from the coitus with the in- 
fected father ; probably it may also be directly involved 



152 THE PATHOLOGY OF PREGNANCY. 

Fig. 96. Placental Infarct in Eclampsia, consisting in subamniotic 
necrotic foci (original water-color drawing after the author's own prepa- 
ration from the Heidelberg Gynecological Clinic ; marginal insertion of 
the cord). 

in maternal infection, and, furthermore, the germ may 
pass from the infected ovum to the healthy mother, bat 
such a mode of transmission to the mother is rare (choc en 
retour), evidently because the fetal specific toxins tend to 
render the mother immune, and she, therefore, usually does 
not, as a rule, become " retro-infected '^ (Colles's law). 

Treatment. — Sodium iodide, gr. iiss to iv to xv (0.15 to 
0.25 to 1 gm.) per day ; calomel, gr. f to iss to iij (0.05 to 
0.1 to 0.2 gm.), three times a day, occasionally as a laxa- 
tive and also for the purpose of mercurialization ; Unna's 
mercurial plaster mulls instead of inunctions, and colloidal 
mercury. A syphilitic infant, or an infant born of syph- 
ilitic parents, although apparently healthy, must never be 
given to a nurse ; neither should a healthy mother nurse 
a diseased infant. The infant should be bathed in subli- 
mate baths (1 gm. in 20 quarts [liters] of water) and 
should receive calomel, gr. -^-^ to -I- (0.005 to 0.0075 gm.), 
and Dover's powder, gr. 2V to -^^ (0.003 to 0.005 gm.), 
three times a day. As regards the physician's consent to 
marriage, it should be given only when five years have 
elapsed from the time of infection and three years from 
the last manifestation of the disease. Immediately before 
marriage the patient should be subjected to an inunction 
cure. The individual should always be cautioned about 
the danger of infection from erosions on the genitalia and 
on the mouth. 

I 13. ECLAMPSIA GRAVIDARUM. 

Whether eclampsia gravidarum (rarely, puerperarum) 
is an infectious disease or not is still an open question. 
That it owes its origin to a specific contagium has never 
been proved and does not appear probable. It is possible 
that compression of the ureters (directly or indirectly as 
a result of stasis in the vascular or lymphatic circulation) 



Tab. 44. 







Fig. 96. 



lf//> A/i.sf E Reichhold. Mmichen 



ECLAMPSIA GRAVIDARUM. 153 

by the entrance of the chilcVs head into the true pelvis is 
foHowed by secondary interference with the renal secretion, 
and that this in turn leads to retention within the blood 
of various kinds of micro-organisms and especially of 
their toxins, or, in other words, ptomains, tlie presence of 
which may produce toxic metabolic products in the 
various organs of the body (leucomains). The explana- 
tion Avhich appears to be most probable is that toxins, 
especially insuiiiciently oxidized products of metabolism, 
are retained as a result of insufficiency of the liver and 
kidneys in individuals whose organisms, owing to their 
neuropathic habit, fails to adapt itself both in the matter 
of circulation and of internal metabolism to the chanws 
in these functions incident to pregnancy. 

If the hepatic and renal insufficiency and the retention 
of metabolic toxins (leucomains) reach a high degree 
toward the end of pregnancy, the nervous impulses at- 
tending the act of respiration give rise to abnormal 
reflexes of the intoxicated nervous system (clonic con- 
vulsions) and to disturbances in the circulation. In this 
way we may explain the acetone and sugar found in the 
urine by Stumpf. as well as the amyloid and fatty degen- 
eration of the kidneys, liver, brain, etc., attended with 
thrombosis and apoplexy or with edema and anemia in 
these organs. Thus, for instance, acetonuria can be pro- 
duced experimentally by excluding the celiac ganglion of 
the sympathetic nerve. 

There is no doubt that pressure conditions and irritative 
processes in the pelvis, involving the sympathetic ganglion 
and the ureters, play an important and very frequent part 
in the etiology. Hence, the first pregnancy — on account 
of the early descent of the head — double and triple 
pregnancies, and generally contracted pelves are counted 
among the predisposing causes. Flat or anteroposteriorly 
contracted pelves do not produce the condition because 
the deeply excavated '' dead space '^ (from an obstetrical 
point of view) alongside of the projecting promontory 
protects the ureters and blood-vessels. There is no single 



154 THE PATHOLOGY OF PREGNANCY. 

Fig. 97. Uterus Bicornis Septus. — Child in first face presentation : 
chin posterior, tlie contractions of the uterus having forced the axis of 
the child's body obliquely against the opposite walls of the pelvis. C}C^^, 
the two coriuia of the uterus ; G.R., contraction-ring. 

Fig. 98. Uterus Introrsum Arcuatus. — Oblique position la with 
shoulder presenting. The depression in the fundus is very marked ; it 
could not be palpated in the foregoing case. Lettering as in Fig. 97. 

Fig. 99. Pendulous Abdomen of tlie Third Degree. — Sagittal section 
showing the position of the child and the vaginal portion of the cervix. 
The fundus of the uterus is lower than the vaginal portion of the cervix 
(original drawing). 



cause, or, to be more exact, there may be a single cause, 
but there is no single exciting cause, to account for the 
outbreak of the symptom-complex which is known as 
eclampsia. The usual time of appearance is during the 
last three months of pregnancy. In isolated cases there 
is no nephritis. 

The symptoms consist in attacks of clonic convul- 
sions, beginning at the head and extending downward. 
The severe headache with debility and oppression observed 
before the attack is replaced by unconsciousness ; the face 
becomes cyanotic, the pulse small and rapid, respiration 
accelerated, sighing or blowing, and accompanied with 
diaphragmatic spasm. The facial and ocular muscles are 
also involved in the convulsions. 

The attack, which lasts from one-half to one and one- 
half minutes, is followed by a condition of coma with a 
rise of temperature and acceleration of the lieart-beat. 
The face becomes pale and pulmonary edema is very apt 
to develop. 

The urine always contains albumin, fibrinous casts 
(also red and white blood-corpuscles), sugar, acetone ; the 
amount is very much diminished and the acidity greatly 
increased. Experiments with the urine and blood indicate 
that they are extremely toxic and contain large masses of 
leucomains. 

Among the prodromal symptoms and consequences of 
an attack may be mentioned headache with nausea and 
vertigo, amblyopia and amaurotic symptoms, pneumonia, 










as 



I 






ECLAMPSIA GRAVIDARUM. 155 

loss of memory for past events, maniacal conditions 
temporary in character and preceded by fits of taciturnity, 
alternating with garrulity, laughter, etc. Oliguria or 
anuria are frequent prodromal symptoms. 

The consequence to the fetus is death, either at the 
time of birth, which is usually premature, or during preg- 
nancy, without, in the latter ca^e, the death of the fetus 
being necessarily followed by delivery, although the 
attacks cease with the death of the child. Sometimes 
children are delivered in a condition of rigidity, and, on 
the other hand, eclampsia neonatorum has been observed 
without any eclamptic symptoms on the part of the mother, 
who, however, suffered from nephritis. Finally, there 
may be changes in the tissues of the placenta such as have 
been described above. After delivery the attacks usually 
cease, but they may be readily provoked by massage of 
the uterus or' the expression of the placenta by Crede's 
method. 

The treatment consists in administering enemata of 
chloral hydrate, gr. xv to xxx (1 to 2 gm.), after every 
attack; siijtoiv (12 to 15 gm.) per day (v. Winckel), or 
subcutaneous injections of morphine as high as gr. ss 
(0.03 gm.) at each attack (G. Yeit has given as high as 
gr. iij [0.2 gm.] in four to seven hours) ; and, finally, in 
administering chloroform, but only for a short time and 
provided the pulse is full and of good tension. Subcuta- 
neous injections of decinormal salt solution. Prolonged 
immersion in a bath of from 97° to 104° F. (36.2° to 
40° C.) or an equivalent warm pack for the purpose of 
inducing diaphoresis is to be recommended. Delivery is 
to be effected as soon as possible, that is, as soon as it can 
be done without danger to the mother, either by dilating 
or incising the os. The patient is to be watched con- 
stantly, and a piece of wood or a spoon or other object 
covered with cloth must be inserted into her mouth to 
prevent injury to the tongue. Every unnecessary disturb- 
ance is to be avoided. Great care must be exercised in 
giving liquids, as inhalation-pneumonia might result. 



156 THE PATHOLOGY OF PREGNANCY. 

Prophylaxis includes the treatment of the nephritis, the 
regulation of the bowels, the induction of diaphoresis, 
and a milk diet. 

§ 14. THE RELATIONS BETWEEN PREGNANCY AND 
DISEASES OF OTHER ORGANS. 

As has been mentioned, general febrile infectious dis- 
eases frequently lead to abortion, either by setting up a 
local endometritis and decidual hemorrhages, or by fa- 
voring the accumulation of heat and the transmission of 
toxins, or, more rarely, of bacteria themselves. In typhoid, 
fever most patients who recover abort. In variola they 
recover without abortion, the children being immunized 
in utero and born with pockmarks, but if abortion takes 
place most patients die. In cholera recovery and death 
occur indifferently with or without abortion. 

Vaccination of the pregnant mother does not, as a rule, 
render the child immune. 

Influenza, according to my observations, leads to pelvic 
congestion and abortion or, more rarely, to premature labor, 
depending on the severity of the epidemic. Abortion is 
less rapid, but often associated with more copious hemor- 
rhage. The placenta is unusually soft ; the subsequent 
discharges are often fetid. The usual nervous phenomena 
of influenza are present and occasionally alternate with 
maniacal conditions. 

The occurrence of erysipelas during pregnancy is a seri- 
ous complication on account of the great danger of septic 
infection during delivery. Cases of septic infection of 
the mother during pregnancy almost always result in 
death of the fetus. Streptococci, staphylococci, and the 
bacterium coli have been found in the blood of such fe- 
tuses. Tetanus has been observed in a few cases, usually 
after an operation. The uterus does not take part in the 
muscular contractions. Although the poison passes through 
the placenta and causes the death of the fetus it does not 
produce abortion directly. 



PREGNANCY AND DISEASES OF OTHER ORGANS. 157 

Scarlatina runs the same cour.se as in non-pregnant 
women. There is a pseucloscarlatinal eruption which 
manifests itself as a sf)ecial form of septic infection dur- 
ing the puerperiiim. In morbilli fetuses have repeatedly 
been born with the eruption of measles in various stages, 
and the eruptive stage can be recognized by the increase 
in fetal movements. 

Impetigo herpetiformis gravidarum is a somewhat rare 
infectious disease of very grave prognosis, for which 
reason it is important to be able to recognize it. It 
appears in the form of vesicles and pustules in the genital 
region and later spreads to tlie abdomen and to the neck ; 
it also attacks the mucous membrane of the intestinal 
tract and leads to hemorrhages from the bowel. The 
disease often results in abortion and frequently in death. 
Timely induction of premature labor is indicated, as the 
disease usually does not appear before the middle of 
pregnancy. 

Otherwise there is no indication to induce artificial 
abortion. 

I also agree with Fritsch in laying it down as a maxim 
that the induction of premature labor is not indicated in 
cardiac disease (digitalis and ether should be employed) 
nor in diseases of the lungs. 

Before deciding that the induction of labor, or, rather, 
the termination of pregnancy, is necessary and more ad- 
vantageous to the woman than delivery at term, we must 
have special reasons based on the individual peculiarity 
and the merits of each particular case. Such indications 
are found in the literature and in the symptomatology of 
cardiac diseases complicating pregnancy. 

If there is perfect compensation pregnancy runs a favor- 
able course if the woman lives a rational life. If com- 
pensation fails the condition usually remedies itself by a 
spontaneous abortion. If the latter does not occur it is 
often possible, by bringing about compensation (digitalis 
except in aortic insufficiency, ether, or venesection), to 
bring the pregnancy to a successful termination. If com- 



158 THE PATHOLOGY OF PREGNANCY. 

Fig. 100, Twisting of the Umbilical Cord and Oligohydramnion of a 
Dead Twin. — The torsion is greatest at the navel. This fetus was re- 
stricted to a very small nutritive area ou the placenta. The cord of the 
other living twin (lodged in the polyhydramniotic sac) presents elon- 
gated arteries with circumscribed accumulations of Wharton's jelly, so- 
called "false knots" (original drawing from a preparation in the 
Munich Gynecological Clinic). 

Fig. 101. Placental Infarcts, wedge-shaped, penetrating deep into the 
choriodecidual tissue, from a case of eclampsia (original drawing after 
a preparation from the Munich Gynecological Clinic). 



pensation cannot be effected the successful result of arti- 
ficial removal of the ovum will depend on the prompt- 
ness with which the ovum is expelled and on the duration 
of the pregnancy ; in other words, on the amount of ex- 
ertion necessary to expel the ovum and, of course, on 
the severity of the disease itself. Labor-pains and the 
changes in blood-pressure which they produce are far 
more dangerous than the alterations in the circulation 
during pregnancy, and we know that a premature delivery 
lasts longer than delivery at term. The best method in 
such cases consists in puncture of the sac, because the 
woman is immediately relieved of her burden. Rational 
indication for the artificial induction of premature labor 
exists, therefore, in those cases in which the cardiac action 
is endangered less by the momentary shock of expulsion 
than by the duration of the circulatory embarrassment, 
especially in aortic valvular disease. 

The mortality given by clinicians, from 30 to 60 per 
cent, (average 40 per cent, in two hundred and fifty cases), 
is too high ; while, on the other hand, the mortality of 6 per 
cent., which was obtained in Gusserow's obstetrical clinic, 
is too low for the conditions met with in private practice ; 
from 10 to 15 per cent, probably represents the true 
figure, depending on whether the woman has previously 
been under the care of a physician or not, as diet and 
proper treatment exert a marked influence on the cardiac 
condition. 

In the case of hard-working women the prognosis 
should be more guarded than in the case of those who 










o 
'3 




PREGNANCY AND DISEASES OF OTHER ORGANS 159 

are able to spare themselves and live a rational life. If 
the lesion is acquired in early youth the prognosis is also 
less favorable. It is also affected by the age of the 
patient, the number of previous pregnancies, and the con- 
sequent using up of cardiac force. For this reason the 
condition of the heart-muscle is quite as important as the 
particular variety of valvular lesion. Myocarditis and 
degeneration of the heart-muscle influence the prognosis 
very unfavorably. The induction of abortion is posi- 
tively indicated before the fourth month if these condi- 
tions are present. In the operation of inducing abortion 
it must not be forgotten that the resisting power of the 
mucous membranes is much reduced by the existing local 
disturbance of the circulation and that they are, there- 
fore, particularly liable to infection. Cardiac shock and 
postpartum hemorrhages are best treated by the applica- 
tion of a sand-bag to the lower part of the abdomen 
(perhaps the inhalation of amyl nitrite or, better, ether, 
but ergotin should never be given). The patient's rela- 
tives should have the desperate nature of the case fully 
explained to them beforehand. Complication with renal 
affection must not be disregarded, as the consequent 
retention of toxins adds another burden to the work of 
the heart. The same is true of gastric, intestinal, and 
he])atic insufficiency. 

The physician may give his consent to marriage except 
in cases of debilitated and very anemic and neurasthenic 
individuals, or when the heart-lesion has been acquired 
early in life and when there is degeneration of the heart- 
muscle and marked failure of compensation, especially if 
there is reason to expect that the woman will have to lead 
a hard life. 

In lung diseases (croupous pneumonia and especially 
phthisis) the course of the pregnancy itself is usually 
favorable ; on the other hand, the act of parturition is 
apt to give rise to grave disturbances on account of the 
loss of blood, the muscular exertion, and the imminent 
danger of cardiac insufficiency and consequent pulmonary 



160 THE PATHOLOGY OF PREGNANCY. 

edema. The rule is to be emphasized that premature 
labor is not to be induced artificially, but as soon as labor 
has begun it should be terminated as rapidly and with as 
little distress to the patient as possible. 

The passage of tubercle bacilfi through the uninjured 
placenta to the fetus, although very difficult, has been 
demonstrated in a few cases, both bacteriologically and 
clinically. 

Finally, it should be mentioned that there are cases 
of hemoptysis during pregnancy which have nothing to 
do either with tuberculosis or with nephritis. 

There is a group of diseases which present the most 
intimate relation with pregnancy : they are the disturb- 
ances of metabolism and nervous diseases. 

Their symptoms depend on toxic effects, due either to 
the formation of abnormal metabolic products or to the 
retention of such products ; in other w^ords, on auto- 
intoxication in its widest sense. In chronic metallic in- 
toxications, such as lead-poisoning, abortion is frequent ; 
the woman should not be allowed to nurse her child, as 
the milk contains lead. 

The theory that hysteroneurasthenic conditions and functional 
neuroses following an auto-intoxication are due to imperfect oxi- 
dation in internal metabolism is constantly gaining ground, and 
finds more and more support in the results of experimental and 
pathological chemical investigations. It is well known that an 
albuminuria may follow violent exertion, that the blood as well 
as the urine of neurasthenic patients contains metabolic prod- 
ucts, both qualitatively and quantitatively abnormal (uric acid, 
phosphates, albumin, \irobilin, leucin, xanthin, hypoxanthin, 
indican, levulose, etc.), and that in the pregnant organism certain 
substances are formed and can be demonstrated in the urine, 
which are capable of producing convulsions and may lead to 
albuminuria and the typical picture of the "kidney of preg- 
nancy." It is true, moreover, that as a result of this relative or 
absolute auto-intoxication the reflex irritability in the central 
nervous system is greatly increased, owing to the anemia which 
results from the congestion in the abdominal walls (vomiting of 
pregnancy), and that in neuropathic pregnant women the already 
existing anomalies of the internal metabolism, including those 
of the thyroid gland, become accentuated and easily lead to renal 



PREGNANCY AND DISEASES OF OTHER ORGANS. 161 

and hepatic insufficiency. The reflexes are, therefore, markedly 
increased, especially if the woman is the subject of a reflex neu- 
rosis (hyperemesis gravidarum, ptyalism, tussis uterina, diarrhea 
gravidarum, eclampsia, icterus gravidarum). 

In various intoxications due to metals, bacterial toxins, 
and toxic metabolic products, including peptotoxins of 
gastric origin with pernicious anemia, the nutrition of the 
motor cells in the anterior horns is usually found to be 
affected earlier than that of the posterior columns, the in- 
verse order being very rare. 

Examination of the urine of eclamptic patients re- 
veals large quantities of leucomains. We also find in 
the urine of women suffering from hyperemesis the fol- 
lowing substances : large quantities of urobilin, which 
may be derived either from hemoglobin or from bilirubin, 
that is to say, either from the decomposition of blood or 
from hepatic disease ; acetone ; peptone usually ; in- 
creased amount of oxalic acid ; skatoxyl ; indoxyl ; a 
large amount of urinary sediment ; hyaline and granular 
casts frequently ; occasionally blood-corpuscles, fatty 
epithelium, triple phosphates, sodium urates, and oxalates 
of calcium. These findings show a marked resemblance 
to the condition of the urine found in infectious dis- 
eases, or, in other words, in intoxications by toxins formed 
within the body. 

Hyperemesis is to be regarded as an exaggerated reflex 
neurosis due to an auto-intoxication, based on a general 
neuropathic habit or in some cases undoubtedly on simple 
hysteria. For practical purposes it is important to dis- 
tinguish three stages : the patient may vomit immediately 
after taking food and be able to retain a little ; the 
patient may vomit from an empty stomach and suffer 
from constant nausea, so that she can take very small 
amounts not only of solid but also of liquid food ; and, 
finally, the patient may suffer from constant retching, 
going on to hematemesis, with insomnia and fever, and 
become very much debilitated ; attacks of syncope, 
icterus, and death may follow, 
n 



162 THE PATHOLOGY OF PREGNANCY. 

The treatment is based on the etioh)gy. It should 
be directed chiefly toward overcoming the hysteroneu- 
rasthenic abulia (loss of will power) ; the ingestion of 
food or medicaments by the mouth should be abandoned ; 
enemata of decinormal salt solutions and diaphoretic 
remedies should be given to stimulate elimination of 
toxins through the skin (wet packs) ; and^ finally, if even 
the administration of an enema provokes the vomiting 
reflex, hypodermic injection of salt solution is indicated. 
As the patient improves she should be made to take large 
quantities of milk and then be put on a gradually in- 
creasing strengthening diet, the bowels being regulated 
by means of enemata and hydrotherapy. Treatment in 
an institution under strict control will prove most effica- 
cious of all. The question of inducing abortion rarely 
needs to be considered, but if it is to be done at all it 
should not be put off too long, as cases have been re- 
ported in which tlie patient succumbed, after spontaneous 
or artificial abortion, to the complete insufficiency of all 
the organs. 

In a number of cases the primary cause is to be found 
in anomalies of the genital organs in connection with the 
same neurotic diathesis. Retroflexion of an incarcerated 
uterus ; spastic conditions of the retro- or anteflected 
uterus wnth descent of the body ; hydramnion ; hydatid 
mole ; decomposition of a hematoma retained in utero, 
twin pregnancy. According to the condition present, 
relief is obtained by the induction of abortion, punc- 
ture of the amniotic sac, freeing the pole of the ovum 
by dilating the cervix without necessarily bringing on 
abortion (Copeman's procedure). Occasionally manipu- 
lations of this kind act by suggestion in hysterical women. 
Mild grades of hyperemesis, especially such as depend on 
a true local dyspeptic trouble, are successfidly treated 
with basic orexine (Frommell), gr. v to viij (0.3 to 0.5 
gm.), in capsules, two or three times a day. 

Ptyalism also occasionally occurs and runs a course with similar 
alarming symptoms. Diaphoresis and diuresis should be stimu- 



PREGNANCY AND DISEASES OF OTHER ORGANS. 163 

lated by hydrotherapeiitic measures (junii)er berry, if there is no 
nephritis) and the bowels moved reguhirly. In regard to drugs, 
I have seen good results follow the administration of atropine or 
of agaricin, unless, as is often the case, hyperemesis exists; potas- 
sium bromide is of no value. I once used agaricin in a case in 
which ptyalism, protracted attacks of violent hyperidrosis, diar- 
rhea, and rellex vomiting alternated at various times and at various 
pregnancies in the same woman. I have noticed this variety of 
nervous diarrhea in pregnant women whose urine contains large 
quantities of uric acid at various times and who inherit the neu- 
ropathic and gouty diathesis. Temporary relief was obtained in 
such cases by bismuth and opium powder, tincture of thebaine, 
proper dieting, and diaphoretic measures. 

Tiissis uterina is undoubtedly a reflex neurosis in many cases and 
is, therefore, to be treated both locally and constitutionally with 
tonics and sedatives. Narcotics must, however, be avoided. 

Icterus gravidarum is usually a symptom of hepatic insufficiency 
associated with hyperemesis, and occasionally goes on to an acute 
yellow atrophy, which is not due to infection, but to intoxication, 
and may give rise to attacks of eclampsia. In a few cases it leads 
to habitual abortion. 

Diabetic symptoms, including pruritus vulvse, are ag- 
gravated by pregnancy in three-fourths of all the cases. 
The fetus is born under weight and greatly debilitated or 
dies in the second half of pregnancy Avith or without 
polyhydramnion. The presence of slight glycosuria 
toward the end of pregnancy is physiological. The in- 
duction of abortion depends on the possibility of checking 
the sugar excretion and the rapid deterioration of the 
entire organism. Otherwise the usual regime is to be 
instituted, which, indeed, according to Kleinwachter's 
extensive studies, is to be preferred in the great majority 
of cases. Diabetic p-irls should not marrv. 

The prognosis in 79r/?»(7?'y grave anemia of pregiiaiicyh very bad ; 
most of the authorities are against the induction of abortion. 
Some cases are reported, however, which have been cured in this 
way. In leukemia induction of abortion or premature labor is 
indicated. 

Hemophilia, purpura hremorrhagica, and scorbutus are very apt to 
cause abortion on account of the hemorrhages ; abortion should 
never be induced artificially. 

Basedow's disease is unfavorably influenced by pregnancy and 
not rarely leads to abortion. 



164 THE PATHOLOGY OF PREGNANCY. 

Many forms of netiritis with hyperemesis which occur during 
pregnancy are evidently to be regarded as due to toxins acting 
especially on the corresponding portions of the spinal cord ; thus 
we have in many cases symptoms of bulbar disease. 

Hysteria is not influenced by pregnancy. Epileptic women 
appear to be improved in one-half of all the cases. Psychoses 
appearing in the first months of pregnancy usually disappear 
after the fourth month, although, strange to say, they not rarely 
reappear during the puerperium ; the prognosis depends on he- 
redity and not on the fact that the woman is pregnant. Melan- 
cholia is the most frequent manifestation. Maniacal symptoms 
may occasionally appear, but only secondarily. Tetany has been 
observed a few times during pregnancy after total or partial ex- 
tirpation of the thyroid gland ; in some cases it appears simulta- 
neously with uterine contractions. 

In chorea the prognosis is very grave, the mortality is 30 per 
cent., and premature labor occurs in 20 per cent, of all cases. 
Induction of abortion is indicated if the case is grave, the prin- 
cipal indication being insomnia. Chronic or acute diseases of the 
spinal cord, such as transverse myelitis, do not interfere with nor- 
mal pregnancy and parturition, although there may be complete 
anesthesia. 

Among renal diseases we distinguish, for practical pur- 
poses, the kidney of pregnancy, chronic nephritis, and pur- 
ulent pyelonephritis. I have seen the latter twice after 
influenza in the fifth and seventh months respectively, and 
in spite of the gravity and long duration of the symptoms 
the cases ended in successful delivery, so that I was very 
glad that I ^had not advised my colleague who was in 
charge of the case to induce premature labor. The 
proper treatment is diaphoresis and, if necessary, nephrot- 
omy. In very rare cases purulent pyelonephritis indi- 
cates an exacerbation of renal tuberculosis. Pregnancy 
and floating kidney do not appear to exert an unfavorable 
influence on each other unless hydronephrosis co-exists. 

The term kidney of pregnancy is applied to certain 
changes of an originally healthy kidney due to mechanical 
influences, or to circulatory alterations, or to the influence 
of toxins. Albuminuria, gradually increasing oliguria, 
the appearance of large masses of fatty morphological 
elements, without red corpuscles but with a few leuko- 
cytes, and edema are the principal signs. 



PREGNANCY AND DISEASES OF OTHER ORGANS. 165 

The prognosis is good unless eclampsia supervenes. In 
pregnant women who have undergone nephrectomy the 
prognosis is good so far as we know (Fritsch). The case 
is different with chronic nephritis. The morbid process 
increases in severity and there is great danger of retinitis 
albuminurica or of amaurosis without ophthalmoscopic 
lesions and with impaired pupillary reaction, and, occa- 
sionally, of amblyopia developing. The condition also leads 
to marked dropsy and to hemorrhages in various mucous 
membranes and even into the placenta. As a result of 
the latter the placenta may be detached either suddenly or 
gradually by sclerosis of the vessels and the formation of 
the placentar infarct (Fehling, cf. Figs. 95 and 96), lead- 
ing to death of the fetus, which is frequently dropsical. 

Treatment must be early and energetic and directed 
to the cure of the renal condition : milk diet, hypodermic 
injections of physiological salt solution, and diaphoresis 
(during eclampsia). If alarming symptoms develop and 
the patient's life is threatened, as In- intense dropsy or 
retinitis, with vision less than one-sixth, premature labor 
must be induced with all proper precautions, so as, if pos- 
sible, to deliver a viable child. In rare cases repeated 
attacks of hematuria of angioneurotic origin have been 
observed in simple hyperemia of the kidneys in Avhich 
the prognosis was favorable. Intestinal hemorrhages 
have also been reported. 

Traumatism during pregnancy may be divided into : 
(c?) Accidental external injuries affecting the organs of 
gestation ; (h) Operations, including as a special group 
operations on the organs of gestation themselves ; (c) 
Criminal abortion performed without the necessary pre- 
cautions and leading to coarse lesions of the organism ; 
(d) Perforating peritonitis and rupture of the uterus or 
of an ectopic gestation-sac during, or subsequent to, 
pregnancy. 

Group (a), or external injuries during pregnancy, includes (]) 
certain special accidents, such as laceration of the abdomen and 
gravid uterus by an angry cow or by the knife of the criminal ; 



166 THE PATHOLOGY OF PREGNANCY. 

in other words, a kind of Cesarean section has been frequently 
reported in the literature, and, in spite of the terrible mutilation, 
the accident did not by any means always result in death. The 
first Cesarean section in Germany was performed during the Mid- 
dle Ages by a swineherd on his own wife, and, although his tech- 
nique was most primitive, the result was favorable. Certain 
tribes of negroes perform the operation with an approach to 
antiseptic measures, such as the use of red-hot stone knives, 
washing the wound with the juice of some plant, and fumigation. 

(2) Gunshot wounds of the abdomen, either penetrating the 
amniotic sac and the fetus, or those in which the bullet becomes 
arrested in the uterine wall and does not injure the ovum. The 
prognosis and treatment depend largely on whether or not the 
ovum has been injured, as I note by a careful examination of the 
cases collected by Neugebauer. In penetrating wounds the amni- 
otic fluid is discharged into the peritoneal cavity and the omentum 
is swept into the wound, hence, infection being almost certain to 
occur, immediate laj)arotomy is indicated, as it is when the intes- 
tines are injured. After the uterus has been evacuated the lips 
of the uterine wound should be resected and sutured and a Miku- 
licz tampon inserted into the lower angle of the wound, so that, 
if necessary, a secondary supravaginal amputation can be per- 
formed in case the uterus becomes infected. After non-perforating 
wounds premature delivery usually occurs within a few weeks, 
although the fetus is generally alive. In such cases expectant 
treatment is indicated unless peritoneal symptoms develop. 

External violence with a blunt instrument, such as a kick, a fall, 
or a blow, while it rarely leads to rupture of the uterus, is often 
followed by separation of the placenta with danger of death from 
internal hemorrhage, or the formation of a hematoma in the 
umbilical cord or fetal membranes by the rupture of large vessels 
in the placenta and in the cord. A common accident consists in 
falling astride of the arm of a chair or other object, leading to 
rupture of the engorged corpora cavernosa in the region of the 
clitoris and threatening the woman's life by hemorrhage. There 
is a specimen in the Munich Gynecological Clinic of a gravid 
uterus with twins which was taken from a woman who died of 
hemorrhage in this way a quarter of an hour after the accident. 
Other similar cases are found in the literature. Compression and 
ligation are the proper measures. 

Group {b). Urgent operations are to be unhesitatingly performed 
during pregnancy. If the anesthesia is not protracted too long 
there is no danger to the fetus. It is always proper to perform an 
operation for the removal of tumors or other obstacles which 
would constitute absolute dystocia at the time of delivery. Car- 
cinomata are always to be operated upon at once. Abortion is 
apt to be induced only by operations directly affecting the uterine 



PEEGNANCY AND DISEASES OF OTHER ORGANS. 167 

wall, such as the enucleation of a subserous intramural myofi- 
broma, or puncture through the abdominal walls for the evacuation 
of hydramnion, and operations on the intermediate and supra- 
vaginal portion of the cervix. Ovariotomy does not, as a rule, 
brfng on abortion. The removal of adnexa or subserous polypoid 
myoniata on one side is usually well borne. The same is true of 
plastic operations on the vagina. Even the operation for appen- 
dicitis is not contra-indicated by pregnancy. As perityphlitis not 
rarely leads to abortion or premature labor, this condition occupies 
a prominent place in the pathology of pregnancy and of the 
puerperium. 

Nephrorrhaphy for the relief of a twisted kidney and local peri- 
tonitis, nephrectomii on account of suspected renal tumors, and 
extirpaiioa of the spleen for traumatic rupture have been successfully 
performed. The abdominal scar becomes markedly pigmented 
during pregnancy, the pigmentation following the line of the scar 
and of the sutures (Fig. 160). 

Group (c). Criminal abortion usually consists in the introduction 
of a sharp instrument for the purpose of rupturing the amniotic 
sac or bringing on labor-pains. If the instrument enters the 
posterior vaginal vault by mistake, or fails to follow the proper 
curve after entering the internal os, the peritoneal cavity is per- 
forated. If aseptic precautions are neglected, septic infection 
develops and ends either in death or in lifelong invalidism. 

Group (c/). Perforation Peritonitis. — This is caused in most cases 
by necrotic pyosalpinx, or the rupture of a peritoneal abscess, or 
of a gangrenous bladder in retroflexion of an incarcerated gravid 
uterus during the fourth month of pregnancy. Death results 
unless laparotomy is immediately performed and iodoform gauze 
introduced into the lower angle of the w^ound for the purpose of 
drainage (see | 13). 

Rupture of the uterus with discharge of the ovum into the peri- 
toneal cavity was a fairly common accident in the days before 
antisepsis, wdien the uterine wound w^as not sutured after Cesarean 
section ; the accident usually ended in death. Now that the 
wound is carefully closed with a double row of silk sutures (if 
catgut is used, diminution in the thickness of the uterine wall 
sometimes occurs at the next pregnancy) the accident is rare. It 
also occurs in ectopic gestation in rudimentary cornua (see | 20 « ; 
15, 1). 

Rupture of a tubal sac in ectopic gestation calls for removal of 
the ovum and blood-clots, either through the vagina or through 
the abdominal w^all, on account of the profuse intraperitoneal 
hemorrhage and the danger of secondary peritonitis (see I 17). 

A special group includes anomalies in the shape and 
position of the pelvic organs, especially of the genitalia, 



168 THE PATHOLOGY OF PREGNANCY. 

which may lead to abortion on account of the want of 
room or the primary and secondary disturbances of the 
circulation. But as abortion under such conditions is a 
comparatively rare occurrence we shall reserve its discus- 
sion for the chapter on disturbances of pregnancy in 
general, which result from those conditions. 

I 15. DISTURBANCES DURING PREGNANCY DUE TO 
ANOMALIES IN THE SHAPE AND POSITION OF THE 
GENITAL ORGANS, ESPECIALLY THE UTERUS. 

1. Malformations of the Uterus. — Uterus unicornis is 
due to the arrest of development of one of Miiller's 
ducts, as a result of which the uterus is imperfectly de- 
veloped ; the organ usually occupies an oblique position 
and is conical at the fundus. The marked attenuation 
of the walls often leads to rupture even during pregnancy. 
The diagnosis cannot be made with any certainty, even 
when there is another rudimentary, secondary horn, unless 
the presence of a septum in the vagina should arouse a 
suspicion of double uterus. There may be impregnation 
of the rudimentary horn which cannot be distinguished 
from extra-uterine pregnancy and gives rise to the same 
dangers, namely, rupture of the gestation-sac as early as 
the middle of pregnancy. 

Uterus bicornis is due to independent development and 
imperfect union of the two ducts. The wider the sepa- 
ration between the ducts the more independent the func- 
tions of the two portions. Thus we observe separate 
labor-pains in uterus bicornis, and if both horns are 
gravid there may be a considerable interval between the 
births of the two fetuses. 

The diagnosis of uterus bicornis is exceedingly difficult, 
as there is only one portio vaginalis. 

Uterus didelphys (duplex), or the development of two 
entirely independent uteri with complete separation of the 
portio vaginalis and either a single or a double vagina, 
one of which may be imperforate. Even in iderus 
septus (bilocularis) regular menstruation and ovulation of 



DISTURBANCES DURING PREGNANCY. 169 

one uterus may continue while the other is impreg- 
nated. Not rarely pregnancy alternates in the two uteri. 
Double pregnancy has also been observed; it gives rise 
to marked disturbances. At every parturition a decidua is 
expelled from the non-gravid side. The diagnosis is 
somewhat easier in the slighter, than in the more pro- 
nounced, anomalies, because in the former the entire com- 
mon portion is occupied by the ovum and, therefore, the 
two horns can be recognized above it (Fig. 98), whereas 
in pronounced forms of the malformation the ovum is 
lodged in one side, the other side undergoing very little 
hypertrophy and being, therefore, difficult to palpate 
(Fig. 97). In this anomaly we occasionally meet with 
premature delivery and rarely with rupture of the single 
gravid horn during the second half of pregnancy, with- 
out the occurrence of labor-pains (case bv Weil of 
Teplitz). 

Toward the end of pregnancy the empty cornu may, 
if it is lodged in the pouch of Douglas, obstruct the 
superior strait like a tumor. 

In abortions, especially if complicated with sepsis, the 
possibility of a double uterus and vagina must always be 
borne in mind. 

Treatment. — In most cases the pregnancy runs a favor- 
able course ; but as a number of cases have been re- 
ported in which rupture occurred and was almost imme- 
diately followed by death, it is important, after such a 
malformation has been recognized, to determine, if pos- 
sible, wdiether the position, fixation, and thickness of the 
Avails of the gravid portion are such as to enable it to 
bring the ovum to maturity. A large number of careful 
observations from the very beginning of pregnancy are 
urgently needed to enable us to determine the expediency 
of inducing abortion in a concrete case. In any case 
pregnancy in a rudimentary horn is to be treated on the 
same principles as an extra-uterine pregnancy. If the 
abdomen is very much distended and tender to the touch, 
either of the palpating hand or of the fetal parts, if there 



170 THE PATHOLOGY OF PREGNANCY. 

Fig. 102. Retroflexion of a Gravid Uterus. — Owing to severe ischuria 
and decomposition of the stagnating urine the entire vesical mucosa has 
undergone necrosis and separated from the wall of the bladder in the 
form of a complete sac (modified after Schatz). 

Fig. 103. Partial Retroflexion of a Gravid Uterus, secondary to total 
incarceration. 

are great emaciation and insomnia, even without elevation 
of temperature, laparotomy is indicated. After septic 
abortion of one horn in double pregnancy the other horn 
is to be immediately evacuated. 

2. Displacements of the Uterus. — Abortion is only rela- 
tively frequent in incarceration of the retroflexed gravid 
uterus. It constitutes a grave complication and is for- 
tunately rare in comparison Avith the frequency of retro- 
version and retroflexion. The displacement is unfavor- 
able to conception and favors abortion both mechanically, 
on account of the position of the uterus, and by the cir- 
culatory disturbances to which it gives rise. 

Retroversion of the gravid uterus, that is, dislocation 
of the fundus backward over the transverse axis of the 
pelvis with the vaginal portion in front, without flexion 
of the body upon the cervix, may become converted into 
retroflexion if the impregnated body of the uterus during 
its growth descends in toto and becomes arrested under 
the promontory. If the fundus is under the promontory, 
but higher than the external os, we speak of the displace- 
ment as a retroflexion of the first degree; if the fundus is 
at the level of the portio vaginalis, it is a retroflexion of 
the second degree; if still lower, it is a retroflexion of the 
third degree. The uterus may be entirely inverted. 
Toward the end of the third month the uterus either 
pushes its way past the promontory, or retroflexion w^ith 
incarceration is produced, which in rare cases may con- 
tinue to the end of a normal pregnancy. If a part of 
the fetus escapes past the promontory we have a partial 
retroflexion of the uterus (Fig. 103). Even then spon- 
taneous reposition may take place during pregnancy by 
the upper portion descending forward and with the assist- 



DISTURBANCES DURING PREGNANCY. 171 

ance of labor-pains exerting traction on the posterior 
lower portion. By the term spurious partial retroflexion 
we mean an anteflexion of the uterus in which there is a 
sacculation of the posterior wall from any cause (uterus 
bicornis with pregnancy in the posterior horn, perime- 
tritic adhesions, myoma — Diihrssen). 

The fetal part originally situated in the hollow of the 
sacrum — usually the head — may, instead of rising, force 
its way downward and eventually cause bulging of the 
perineum (Fig. 105) or of the wall of the rectum ; or, 
after perforating the posterior vaginal wall, may cause 
prolapse of the retroflexed gravid uterus (Fig. 109) and 
appear at the vulva. The consequences of this accident, 
aside from spontaneous reduction with or without abor- 
tion, are hyperemesis, ptyalism, cystitis with abortion 
(retention and decomposition of the urine with necrosis 
and separation of the vesical mucosa. Fig. 102), halving 
of the bladder in such a way that one part is in front and 
the other behind and upon the uterus, and, finally, per- 
foration of the rectum and vagina, or usually fatal rupture 
of the bladder and uremia ; occasionally death of the 
fetus. 

Paradoxical ischuria with absence of the menses is 
always an important factor in the diagnosis. Examina- 
tion of the size and position of the uterus must never be 
neglected. The diagnosis can be definitely established by 
finding the angle between the portio vaginalis and the 
posterior part of the tumor continuous with it. The 
tumor gives rise to a spherical bulging of the posterior 
vaginal vault. The condition must be differentiated from 
tubal pregnancy with chronic adliesive peritonitis and co- 
existent retroflexion of the uterus, and from retro-uterine 
hematocele. 

I once met with a case of the first kind which I was 
unable to diagnosticate in the second, or even in the third 
month until after the reposition of the somewhat enlarged 
and softened uterus, when I was able to demonstrate by 
palpation the growing tubal tumqr. In such cases reposi- 



172 THE PATHOLOGY OF PREGNANCY. 

Fig. 104. Von Wiuckel-Eisenhart's case of Hernia Labialls Uteri 
Gravidi Bicornis : (7^ C^, cornua uteri ; 8, septum. 

Fig. 105. Stage of Transition to Prolapse of the Retroflexed Gravid 
Uterus, with perforatiou through the rectum or vagina or through the 
perineum. 

tion should not be attempted even after the state of 
affairs is accurately known, on account of the danger of 
immediate rupture of the sac. 

Etiology. — Predisposing factors are firm adhesions, flat 
pelves with projecting promontories, tumors, a primary 
relaxed condition of the uterine walls, which become 
thickened by chronic metritis when these conditions are 
complicated with constant retroversion of a deeply placed 
uterus. 

The first indication in the treatment is reposition, 
after evacuation of the bladder and rectum. Reposition 
is effected by drawing down the cervix with Muzeux 
forceps and pushing up the body of the uterus, either 
through the posterior vault or, in a standing or in Sanger's 
position (elevation of the pelvis), through the rectum or, 
possibly, through the abdominal wall. In many cases 
reposition requires the introduction of the round elastic 
Mayer's ring-pessary or of the colpeurynter (A. Miiller), 
that is, a rubber bladder which is inflated after its intro- 
duction, care being had not to exert too great a pressure 
and thus rupture the vaginal vault. In order to evacuate 
the bladder it is sometimes necessary to raise the vaginal 
portion of the cervix and push it away from the symphy- 
sis. In gradual reposition by elastic pressure Sims's 
lateral or the knee-elbow position is sometimes employed 
(Fig. 63). Up to the sixth month the organ may be 
kept in position by a lever-pessary or by means of around 
smooth ring. 

If reposition is impossible, even under anesthesia and 
after dilatation with the colpeurynter, and if the urine 
becomes bloody and begins to decompose, puncture of the 
bladder should be performed ; as there is danger of the 
connective tissue surrounding the bladder becoming in- 



4 



s 





DISTUBBA^X'ES DUBIXG PREGNANCY. 173 

filtrated with uriiK^ it is best to open the viscus through 
the vagina ; or premature labor should be induced with 
a sound or a curved bougie ; or, if the os cannot be 
reached, the ovum is punctured through the posterior 
vaginal and uterine wall ; or, in extreme cases, Cesarean 
section through the vagina under absolute asepsis. In 
exceptional cases it may be possible to preserve the ovum 
by replacing the uterus through an abdominal section. 
Forced reposition may lead to rupture of the gangrenous 
bladder and fatal peritonitis. 

(«) Prolapse of the gravid uterus occurs only in the 
first half of pregnancy ; incomplete prolapse, due to 
hypertrophy of the cervix — in which the fundus of the 
uterus, as a rule, occupies the usual positions at the 
various periods of pregnancy, being pushed upward by 
the tension of the vaccinal walls and held above the 
superior strait by its own dilatation — may develop during 
pregnancy, but in most cases the condition is present be- 
fore pregnancy occurs. Prolapse may also be caused by 
ovarian tum )rs without hypertrophy of the cervix (see 
Fig. 109), or it may be brought about by external 
mechanical influences, such as cough or violent bearing 
down, when the suspensory apparatus of the uterus is 
weak. 

In one-third of all the cases prolapse does not occur 
until the onset of labor ; for instance, it may imme- 
diately follow a labor-pain when the lower uterine seg- 
ment is rigid and very resistant. It is never due to ab- 
normal size of the pelvis or of the vulvar opening unless 
the floor of the perineum is weakened. A special variety 
of prolapse consists in the descent of the edematous and 
markedly hyperemic swollen anterior lip of the external os, 
without anatomical elongation, into or beyond the vulva. 

In those cases in which the uterus supports itself above 
the superior strait during the second half of pregnancy, 
postpartum prolapse is very apt to occur. 

The relaxation of the pelvic organs not only gives rise 
to descent and prolapse of the uterus, but is a frequent 



174 THE PATHOLOGY OF PREGNANCY. 

cause of premature expulsion of the ovum. Prolapse 
itself predisposes to abortion on account of the distortion 
and consequent disturbances to the circulation. 

For these reasons the condition requires treatment 
during pregnancy, the best procedure being the introduc- 
tion of a Mayer's hard-rubber or celluloid ring-pessary, 
which is left in place until the sixth or eighth month, or 
a plastic operation for prolapse may be performed. In a 
number of cases of so-called habitual abortion without 
marked prolapse of the uterus, but with descent of the 
uterus w^hich was retroverted in the non-gravid state, 
owing to weakness of the suspensory and circulatory ap- 
paratus (chronic congestions and stasis), the author has 
seen this treatment followed by normal delivery of the 
child at term and relief of all the symptoms which had 
marked previous pregnancies. Abortion and premature 
delivery are very apt to bring on septic endometritis on 
account of the lacerated condition of the external os. 

(6) Anteflexion of the uterus is of no special significance 
unless it is associated with pendulous abdomen or depends 
on inflammatory or operative wounds resulting in peri- 
metritic adhesions or fixations (hysteropexy, vaginal and 
vesical fixation, ventral fixation), which render the organ 
absolutely immovable. 

Since B. S. Schultze's investigations we know that the 
non-gravid uterus is normally inclined forward, and in 
vigorous organs, especially such as have already borne 
children, a slight anteflexion is added. During the first 
months of gestation this anterior position of the organ 
becomes accentuated on account of its increase in size and 
weight, as may be observed at each menstruation ; the 
body of the uterus sinks deeper into the bladder, so to 
speak, the portio vaginalis rises, and the whole organ ap- 
pears "tipped over" forward. Even in cases of retro- 
flexion ])regnancy nearly always effects a spontaneous 
replacement and anterior flexion of the uterus or, if the 
posterior wall is fixed by perimetritic adhesions or by 
tumors, anteflexion with posterior sacculation takes place. 



niSTUBBAKCES DURIXG PREGNANCY. 175 

When the abdominal walls are relaxed this tipping 
over forward is desio^nated as an excessive ''anteversio- 
flexio uteri " with pendulous abdomen, a condition which 
may give trouble in many Avays and may even form a 
serious complication of labor. 

The condition occurs most frequently in flat or antero- 
posteriorly contracted pelves, partly because the weight 
of the gravid uterus is not sufficiently supported by the 
anterior pelvic wall and partly because such a pelvic 
deformity is usually found in hard-working, badly nour- 
ished individuals with defective nervous tone, who had 
been rachitic in earlv life. As a result the mobilitv of 
the uterus is much increased, and in some cases there is a 
distinct flattening due to flaccidity or oblique distortion 
with a corresponding attitude of the fetus up to the 
moment of labor and even during its progress. The 
diminution in the available space, especially of the true 
pelvis in contracted pelves and the shortening of the 
abdominal cavity in scoliosis, also predis])oses to ante- 
flexion of the uterus. The same may be said of marked 
lumbosacral lordosis in rachitic women and of transversely 
contracted, oval pelves during the first months of preg- 
nancy, because the symphysis is displaced forward and the 
fundus of the uterus thereby loses its normal support. 

The predisposing factors in the abdominal walls are a 
relaxed condition, separation of the recti muscles, diminu- 
tion in the thickness of the fascite and of the panniculus 
adiposus ; those on the part of the ovum are hydramnion 
and twin pregnancies. 

During the first half of pregnancy the fundus is still 
supported by the symphysis, the portio vaginalis being 
directed posteriorly. A true pathological fixation in ante- 
flexion can exist, or at least continue to exist, only when 
there is some form of abnormal fixation.' 

^It is to be remarked in tliis connection that the body of the uterus 
normally descends durinor the first two months on account of its in- 
creased weight (Figs. 19 and 33), and thus forms an obtuse angle with the 
cervix. This phenomeuon occurs again toward the end of pregnancy 
when the head enters the true pelvis (see J 1, ad finem). 



176 THE PATHOLOGY OF PREGNANCY. 

During the second half of pregnancy the fundus pro- 
jects beyond the symphysis, forming either an obtuse 
angle with the anterior pelvic wall (first degree of pendu- 
lous abdomen, Fig. 128) or a right angle, so that the 
navel forms the most prominent part of this so-called 
"conical abdomen " (second degree, Fig. 127) ; or it may 
make an acute angle, so that the fundus uteri stands at 
the same level as the portio vaginalis or even lower (third 
degree. Figs. 99 and 129), and the abdomen rests on the 
thighs when the woman is sitting down, or, in extreme 
cases, when she is in the upright position. 

In the case of abnormal inflammatory adhesions, resist- 
ing even the softening influences of pregnancy, especially 
an excessively high anterior vaginal fixation of the uterus 
secondary to an operation, the anterior uterine wall may 
remain rigid and unyielding and the ovum thus develop 
entirely within the posterior wall, which, unless the ovum 
is prematurely expelled, undergoes an alarming degree of 
dilatation and presents the picture of partial retroflexion of 
the gravid uterus. This condition may occur even with- 
out the existence of abnormal adhesions in simple retro- 
version of an anteflexed uterus during the last months of 
pregnancy, on account of the head developing within the 
posterior lower uterine segment, especially if the abdomen 
is pendulous ; in these cases the portio vaginalis is forced 
against the symphysis. Abortions have been repeatedly 
observed after hysteropexy. Abnormal fixations also lead 
to torsions through a quarter of a circle and to lateroflex- 
ions with secondary sacculations. 

Another symptom which has been repeatedly men- 
tioned and again discarded by various authors as follow- 
ing a marked anteflexion of the uterus (with or without 
occasional incarceration at the symphysis or partial con- 
vulsive contractions) is hyperemesis gravidarum. 

I have convinced myself of the occurrence of this 
symptom in various instances, and always in hystero- 
neurasthenic and anemic individuals with infantile ante- 
flexion of the uterus, which I had observed to be present 



TUMORS. Ill 

in them before marriage ; that is to say, the imperfectly 
developed body of the uterus formed an acute angle with 
the long, thin cervix, Vvhose axis corresponded with the 
long axis of the vagina. Such women usually suffer from 
colic due to dysmenorrhea even before they become 
pregnant. 

(c) A rare anomaly is hernia of the gravid uterus or hysterocele, 
which may also be easily mistaken for an ectopic gestation. The 
gravid uterus may be found in an inguinal or in a ventral hernia 
or even in the sac of a femoral hernia. So far as has been ob- 
served, gestation is not interrupted by an inguinal hernia, but 
neither does spontaneous reposition or natural delivery take place 
in that condition. The head of the fetus usually lies toward the 
mouth of the hernia, showing that the position of the child de- 
pends on the configuration of the uterus. 

The uterus may undergo secondary distortion within the hernial 
sac ; a few cases of this kind are congenital, especially in uterus 
bicornis or unicornis. Tubal pregnancies in inguinal hernia are 
very rare (Jordan's case in Heidelberg). 

To establish the diagnosis it is necessary to prove a connection 
between the portio vaginalis and the tumor within the hernial sac. 
The palpation of fetal parts within the latter establishes the diag- 
nosis of pregnancy. 

Treatraent. — Eeduction, or else induction of abortion. Cesarean 
section, or herniotomy and removal of the uterus or of the gravid 
cornu, as in v. Winckel's case, which is illustrated in Fig. 104, 
or of the tubal sac (Jordan), or dilatation of the hernial opening 
with the knife (P. Miiller). 

I i6. TUM0R5. 

Tumors which encroach upon the true pelvis, whether 
they emanate from the genital or from neighboring organs, 
or enter the superior strait like movable kidneys or hydro- 
nephrosis, may give trouble even during pregnancy. 

(a) Fibromyoma. — Fibromyoma of the uterus, rarely of 
the vagina, is much less frequently met with, either in the 
pregnant or in the puerperal woman, than the experience 
of gynecological practice would lead us to expect. The 
reason is not so much that a woman with a tendency to 
have tumors is less apt to become pregnant, but that 
the tumors do not, as a rule, develop before the thirty- 
fifth year or toward the end of the child-bearing period. 

12 



178 THE PATHOLOGY OF PREGNANCY. 

Most tumors, especially the smaller ones, are not diag- 
nosed during pregnancy, although, on the other hand, 
large tumors have occasionally led to the diagnosis of 
twins. If a tumor does make itself felt during pregnancy 
or parturition the prognosis is very grave, both for the 
mother and for the child ; hence, if during pregnancy we 
discover a tumor whose size and position render it danger- 
ous in itself or in connection with parturition, or cause 
alarming symptoms, say, in the peritoneum, the kidneys, 
the lungs, and the heart, removal of the tumor alone, or, 
during the earlier months of pregnancy, of the entire 
uterus, is indicated. 

Myomata on the posterior wall of the gravid uterus 
may by their weight give rise to retroversion and incar- 
ceration of the organ under the promontory and lead to 
abortion or to the same symptoms which we have learned 
in connection with retroflexion and incarceration of the 
gravid uterus (retention of the urine). In either condi- 
tion spontaneous replacement is impossible. 

In pedunculated, movable, subserous myomata we may 
have torsion of the pedicle leading to necrosis of the 
tumor, to adhesions with loops of intestine, and eventually 
to peritonitis. In the same way a large intramural tumor 
may undergo softening and decomposition and thus bring 
about further infection of the organism and peritonitis. 
This condition, like the rapid growth of a tumor during 
pregnancy, gives rise to marked symptoms and calls for 
immediate operative interference. The nearer a subserous 
tumor lies to the cervix, the greater the probability of its 
becoming troublesome. 

Fibromyoma is a tumor consisting of muscular and connective 
tissue, the latter undergoing marked proliferation as the tumor 
grows. The tumor originates in the muscular wall of the uterus 
or vagina, that is to say, it is at first intramural (intraparietal), 
beginning in the muscular layer of the body of the uterus and 
extending either toward the mucosa or toward the serous surface, 
or becoming iutraligamentary, that is, growing between the two 
layers of the broad ligament, or, finally, sinking into the cervix. 
A projecting tumor may eventually draw out a vascular pedicle, 



TUMORS. 179 

in other words, may become polypoid. This variety includes 
particularly the fibrous polyps which mav attain a very consider- 
able size (as large as a child's or a man's' head), in contradistinc- 
tion to the small, soft, mucous polyps, consisting only of the 
elements of the mucous membrane. The latter may 'occur in 
connection with fibromata, as the mucous membrane always tends 
to proliferate with both submucous and intramural myomata. 
From this swollen, hypertrophied, and fungous endometrium 
originate the profuse menorrhagias and metrorrhagias which form 
the characteristic symptoms of uterine mvoma in the non-preo*- 
nant state. " ° 

The effect of a fibromyoma on pregnancy consists in 
premature expulsion of the ovum, deformity of the fetus, 
abnormally low insertion of the placenta,' not far from' 
and just above the internal os (placenta pr^evia), or, rarely, 
ectopic gestation with severe subjective symptoms. 

The tumors act (1) by diminishing the space, (2) by 
producing retroversion of the uterus, and (3) by setting 
up circulatory disturbances and the above-mentioned 
structural changes in the endometrium, which continue 
after the mucous membrane has been converted into 
decidua. 

As a result of these changes, rarelv from metrorrhao-ia 
alone, abortion occurs, or else the fetus dies and leads^o 
premature labor, which often becomes habitual. It must 
be remembered that this accident, which occurs in 15 to 
20 per cent, of the cases, is often followed bv retention 
of portions of the fetal membranes ; hence, careful cu- 
rettage should never be nedected. As a result of the 
encroachment of the tumor the child is unable to develop 
(deformity, see Fig. 108), or the ovum becomes attached 
in an abnormal location : in the lower uterine seo^ment, as 
in the case of placenta prsevia, which is so often'observed 
with submucous myomata, or in the tube in the form of 
an extra-uterine pregnancy, either because the uterine 
orifice of the tube is too ' small for the passage of the 
impregnated ovum or because its progress toward the 
uterus is obstructed by the inflammation and swelling of 
the mucous membrane. 

Failure of conception is sometimes explained bv the 



180 THE PATHOLOGY OF PREGNANCY. 

Fig. 106. A Fibromyoma, springing from the lower uterine segment and 
posterior wall of the cervix, fills up the true pelvis and blocks the su- 
perior strait so that the head cannot enter the pelvis. The head becomes 
displaced forward and permits the hand to prolapse ; that is, to slip 
under it into the anterior pole of the amniotic sac. The head is forced 
down upon the symphysis. The body of the tumor completely fills the 
lateral half of the pelvis. If the condition is allowed to go on until 
parturition, it may lead to lateral deviation of the head against the body 
of the iliac bone, to face presentation, or to oblique position of the fetus. 



presence of submucous and interstitial or polypoid and 
cervical myoniata, both on account of the structural 
changes and active secretion and hemorrhages of the 
hypertrophied mucous membrane, and on account of the 
mechanical blocking of the cavity of the uterus and of 
the internal os. Large subserous tumors may have the 
same effect by causing displacement or acute flexion of 
the adnexa (Fallopian tubes, ovaries). 

This form of sterility is, therefore, the result of myo- 
matosis. It is probable that there is also some primary 
cause for the development of myomata and for this abso- 
lute or relative sterility, but the connection has never 
been proved. It could not, in any event, be regarded as 
a law governing each individual case, but rather as a more 
or less frequent combination of co-existent symptoms of 
degeneration. 

Among the effects of pregnancy on the growth of myo- 
mata we have already mentioned : first, the rising of the 
tumor and its incarceration below the promontory, condi- 
tions which have been found after the death of the child 
at the end of pregnancy ; second, torsion of the pedicle 
with secondary softening and necrosis ; third, necrosis due 
to disturbances of the circulation or to hemorrhages (ten- 
dency to thrombosis of the veins of the adnexa) ; and, 
fourth, rapid growth of the tumors. 

The latter is due not so much to the increase in the 
number and size of the fibers as to a serous infiltration or 
edema which rapidly subsides during the puerperium ; 
the fibrous elements show the greatest degree of prolifera- 



Tab. 49. 




>- 



Fig. 106 



l.ilh.AnMi F 'RuirJihnfri yiir.rhnr. 



TUMORS. 181 

tioii. Xiimerical increase of the muscular fibers is ob- 
served only in true intramural tumors. 

Fifth, the shape of the tumor adapts itself to the wall 
which forms its native soil, and therefore depends on the 
degree of distention ; in most cases it becomes flattened 
and increased in its long diameter. This process may 
often give rise to central hemorrhagic or softening foci, 
which present a fruitful soil for the development of infec- 
tious germs (sloughing). 

Sixthj a special form of displacement of the tumor 
consists in the loosening of the polypoid submucous or 
cervical myomata from their foundations and subsequent 
expulsion — the so-called birth of the tumor. 

The diagnosis of a pregnancy complicated by the 
presence of a tumor is often very difficult. Small tumors, 
as a rule, either escape detection or pass for fetal portions, 
or they may even lead to the diagnosis of twin pregnancy. 
Large tumors are usually recognized without difficulty on 
account of their hardness, but not so the co-existing preg- 
nancy, especially during the earlier months. In cases of 
intramural, cervical, and multiple myomata there is un- 
fortunately an entire absence of Hegar's sign, or doughy 
consistency of the uterine wall about the internal os, and 
of the usual softness and lack of resistance to the finger 
of the body of the uterus. The entire list of probable 
signs of preguancy must be reviewed and the presence of 
a soft tumor containing the fetus in juxtaposition to the 
hard myoma must be determined under anesthesia before 
the diagnosis can be established. It is to be remembered 
that the gravid uterus may be below and behind the 
tumor, and in such a case the body of the uterus with its 
contents can be palpated with the finger introduced into 
the rectum. 

The diagnosis is often obscured by softening of the 
tumor simulating fluctuation, and by the fact that on the 
one hand the presence of a tumor alone is sometimes suf- 
ficient to cause mammary secretion, and, on the other 
hand, more or less copious periodical hemorrhages may 



182 THE PATHOLOGY OF PREGNANCY. 

Fig. 107. First Face Presentation due to au obstructing myoma of tlie 
cervix which has become detached from the wall and been "born" 
before the child (placenta prsevia marginalis). 

Fig. 108. An Enormous Subserous Uterine Myoma prevents the en- 
trance of the fetus into the true pelvis and gives rise to au abnormal 
presentation and attitude; deformities due to protracted diminution of 
the space and compression. (Both original drawings; Fig. 108 after a 
specimen in the Munich Gynecological Clinic.) 



persist in spite of the existing pregnancy. While in 
most cases repeated examinations with a view of deter- 
mining the true nature of a tumor simulating pregnancy 
and of the rapid growth of one of the tumors or of the 
entire mass, with the typical concomitant symptoms, 
usually enable the examiner to arrive at a satisfactory 
conclusion, it occasionally happens that without incising 
the uterus a diagnosis cannot be reached even after the 
abdominal cavity has been opened. 

The treatment during pregnancy follows naturally 
from the diagnosis and from the prognosis, it being re- 
membered that the latter is to include the probable effects 
of labor and a consideration of the best methods to pre- 
serve the life of the child. Hence the proper estimation 
of such cases is of the utmost importance for every 
physician. We have the following possibilities before us : 

1. Inaction following the development of events suh 
partu, "armed expectancy." 

2. Inaction until labor-pains have begun. 

3. Inaction until the child has become viable : (a) in- 
duction of premature labor ; (b) Cesarean section, either 
to be preceded or followed by removal of the tumor or of 
the uterus. 

4. Inaction until the advent of violent subjective symp- 
toms or until there is imminent danger to the woman's 
life (by infection, especially in thrombosis) ; then, 

5. Inaction, attempt at reposition. 

6. Immediate removal of the tumor during the first 
months without interrupting pregnancy : (a) through the 
vagina (removal of polypi, enucleation of cervical myo- 








o 



TUMORS. 183 

mata) ; (h) by celiotomy (removal of subserous polypi), 
myomectomy. 

7. Supravaginal amputation of the gravid uterus by 
abdominal section during the first months. 

8. Total extirpation of the gravid uterus. 

9. Induction of premature labor or abortion^ followed 
either immediately or later by removal of the myoma, or 
without such removal. 

The prognosis of myomectomy during pregnancy is not 
very encouraging : 20 per cent, maternal and 45 per cent, 
fetal mortality. On the other hand, Stavely^s statistics 
of five hundred and ninety-seven non-operated cases yield 
a death-rate of 37 per cent. 

If a myoma is discovered during the early months of 
pregnancy the first question should be : ^^ Are there any 
marked subjective symptoms ? '^ ; the second : " Are such 
symptoms to be expected before the child becomes 
viable ? '^ ; and the third : '^ AYill the advent of labor at 
term give rise to dangers which at that time will be prac- 
tically insurmountable ; in other words, endanger the life 
of both mother and child ; is the immediate removal of 
the tumor less dangerous than a subsequent removal would 
be?" 

To answer these questions w^e need an exact knowledge 
not only of the condition of aflPairs at the time and of the 
general condition of the mother, but of the behavior dur- 
ing pregnancy and parturition of the particular variety of 
myoma present. To settle this point the above-mentioned 
data are of the highest value. 

The first things to be considered are the size and situa- 
tion of the tumor. 

Small tumors within the body of the uterus should 
never be interfered with, although they may produce post- 
partum hemorrhage during the puerperium. 

Cervical jyolypi are to be removed at once. Broad 
cervical tumors seated within the wall are best let alone 
until the beginning of labor, as their enucleation is very 
apt to give rise to profuse hemorrhages and other alarm- 



184 THE PATHOLOGY OF PREGNANCY. 

ing symptoms, and to abortion. The same is true of all 
submucous myomata. The gaping wound which remains 
after their removal always involves great danger of hem- 
orrhage or infection, either before or after expulsion of 
the ovum. Enucleation itself is quite easy on account 
of the relaxed condition of the tissues. 

In large myomata situated in the cervix the possibility 
of immediate or subsequent replacement is first to be con- 
sidered. 

As in all the following large varieties of myomata we 
must remember first of all the law that a tumor, on the 
one hand, grows very rapidly during pregnancy, while, 
on the other hand, its form tends to adapt itself to the 
growth of the uterus, that is, the tumor becomes flattened 
and increased in its long diameter, so that the rising of 
the gravid uterus into the abdominal cavity, assisted by 
the labor-pains, may suffice to draw the softened tumor 
above the superior strait even in cases in which unsuccess- 
ful attempts at reposition have been made under anesthe- 
sia, and that thus the head or the breech may be permitted 
to engage. This is an important point to remember. 

If the true pelvis is blocked by a large cervical myoma 
no attempt at reposition must be made before the eighth 
month of pregnancy, on account of the danger of abortion, 
unless symptoms of incarceration make their appearance. 
After that period, however, and especially at the onset of 
labor, reposition must be performed under all circum- 
stances (if necessary in the lateral or knee-elbow position 
through the vagina and rectum ; see methods of reposition 
in retroflexio uteri, §§15 and 20). 

If reposition of the tumor is impossible, and if it ap- 
pears to be so tightly wedged in that the uterus will in 
all probability not be able to draw it upward, it must be 
removed through an abdominal section. The question 
whether spontaneous reposition is likely to take place is 
extremely difficult to decide. 

The treatment of subserous myomata wedged into 
the true pelvis underneath a gravid uterus is subject to 



TUMORS. 185 

the same considerations ; since the possibility of sponta- 
neous or artificial reposition is greatest in these cases the 
induction of premature labor is adapted to them. The 
indications for this procedure are the same as in contracted 
pelves. As, owing to the rigidity of the structures and 
the interference of the myoma with the strength and regu- 
larity of the contractions, there is frequently insufficient 
dilatation of the cervical canal and of the lower uterine 
segment, podalic version is to be preferred in such cases 
on account of its dilating action on the cervix. 

If portions of fetal membranes are retained, or sepsis 
develops after abortion or parturition (metrophlebothrom- 
bosis), and should intra-uterine irrigation and curettage 
prove unavailing, immediate total extirpation is indicated. 

The '^ ideal moment '^ for myomectomy through an 
abdominal incision is the end of pregnancy, because the 
life of the child is thus preserved and the danger to the 
mother is not materially increased, as the greater size and 
vascularity of the tumor are counterbalanced by its 
accessibility and the facility with which it can be enucle- 
ated. Kemoval of pedunculated subserous myomata is 
more justifiable because less apt to bring on an abortion 
than enucleation. 

Myomectomy by celiotomy is indicated in the case of 
larger subserous, intraligamentary, or intramural tumors, 
and in large myomata of the cervix, whenever their 
growth or position, or the occurrence of softening, threaten 
to make them troublesome. Immediate operation is in- 
dicated only by the presence of intense subjective symp- 
toms or imminent danger to life, such as twisting of the 
pedicle, irremediable incarceration, peritonitis, suppura- 
tion, and complicating organic diseases that typically 
accompany myomata (diseases of the heart, lungs, and 
kidneys). 

In cases of this kind supravaginal amputation of the 
gravid uterus without evacuation is to be considered as 
long as the fetus is not viable ; after the eighth month 
Cesarean section should be performed, followed by Porro's 



186 THE PATHOLOGY OF PREGNANCY. 

Fig. 109. Total Prolapse of Retroflexed Gravid Uterus, due to pressure 
of a large pedunculated ovarian cyst on the left side, completely filling 
the true pelvis and reaching to the navel above; ischuria; rectocele. 

Fig. 110. Transverse Rupture of the Uterus {Ru.), due to thinning 
of the wall by a cancerous ulcer of the cervix ([/"^c.) ; anteflexio uteri 
puerperalis ; PL, placental site ; C.B., contraction-ring ; A.Mm., external 
OS (the preparation is shown in sagittal section). 

amputation. The stump is best disposed of by return- 
ing it into the peritoneal cavity. If the fetus is dead at 
this time, total extirpation without opening the uterus is 
often more advisable. Cesarean section alone is very 
dangerous and cannot be considered a rational mode of 
treatment. Total extirpation is more dangerous on 
account of the greater technical difficulty (although this is 
not always the case), the longer duration of the operation, 
and the necessity of opening the vagina. On the other 
hand, this operation gives the best hope when infection 
already exists, as well as with tumors which are so deep- 
seated that the vagina would in any case have to be 
opened, as in large myomata of the cervix. 

(6) Ovarian Tumors. — Like certain myomata of the 
uterus, ovarian tumors often interfere with conception, 
but ovarian cysts do not show the same tendency to rapid 
growth during gestation ; much more frequently they 
begin to grow after postpartum congestion is established. 
As intimated at the beginning of this section ovarian 
tumors rarely accompany pregnancy, although evidently 
not because of any sterility of the ovarian tissue due to 
the presence of the neoplasm, since cases of large bilateral 
ovarian tumors accompanying pregnancy have been re- 
ported. 

Although pregnancy and parturition have occasionally 
been brought to a successful termination, yet the danger 
is so great as to constitute an absolute indication for the 
immediate removal of the tumor as soon as the diagnosis 
is established. 

As the fundus of the uterus rises in the abdominal 
cavity it exerts a marked traction on the stalk of the 




f^ 




O 






TUMORS. 187 

tumor, the insertion of Avliicli becomes relatively more 
and more deep, and thus circuhitory disturbances are pro- 
duced. In other cases the uterus has a tendency to rotate 
the tumor and jiroduce a fatal torsion of the pedicle 
which is followed by necrosis and peritonitis; finally, if 
the wall of the tumor is brittle, the direct pressure on it 
may cause it to rupture. If the tumor is small it may 
remain within the true ])elvis under the promontory and 
thus block the entrance of the head when labor sets in ; 
this complication is particularly apt to occur in cases of 
massive ovarian fibromata, which, although fortunately 
rare, show a marked tendency to attain this fatal medium 
size. 

Conversely, the tumor may be wedged in the superior 
strait and retain the uterus in a position of retroflexion 
and incarceration, or it may lead to incarceration of the 
uterus and thus bring on abortion. The latter may also 
occur without a complicating retroflexion. 

The diagnosis of this complication must be made 
early, and it is therefore of the greatest importance for 
every physician to be able to recognize the condition with 
certainty. The complication is productive of great 
danger both during pregnancy and during parturition, 
and it is usually accompanied early by marked subjective 
symptoms. The usual symptoms of pregnancy are in- 
tensified and early become recognizable on account of the 
marked pressure, as in twin pregnancies. To these are 
added the discomfort of the tumor itself and the com- 
Dlications due to both conditions combined (diminution 
of the available space, constipation, vascular symptoms, 
torsion of the pedicle of the tumor, retroflexion, inflamma- 
tions, etc.), so that a thorough examination is demanded. 

The diagnosis is based on the demonstration of preg- 
nancy ; in other words, the presence of a gravid uterus 
and an additional tumor connected to it only by a pedicle. 
If the two tumors are moved in opposite directions with 
the hand the pedicle is stretched and may be palpated 
through the abdomen, vagina, or rectum. 



188 THE PATHOLOGY OF PREGNANCY. 

Among the larger ovarian tumors to be contiidered in this con- 
nection the most frequent are multilocular glandular myxoid cysts; 
they are rarely large enough to constitute an obstacle to labor. 
The tumors are made up of numerous communicating cysts of 
varying sizes filled with a mucocolloid material. As they grow 
from the ovary they are connected with the uterus by a pedicle, 
consisting of the ovarian ligament, the vessels, and the tube. 

These tumors are not in themselves malignant, but they may 
be accompanied by firm papillary proliferations which may take 
on a carcinomatous character by a typical proliferating metastasis. 
The cysts themselves are dangerous on account of their unlimited 
growth, of their exhausting eff'ect on the entire body, and of the 
liability of the pedicle to become twisted, thus cutting off the 
blood-supply and leading to necrosis. 

Dermoid cysts are recognized by the characteristic feel of their 
sebaceous contents, which are mixed with bones ; they may also 
degenerate into carcinomata. It is evident, therefore, that these 
tumors all require speedy removal. 

In the differential diagnosis the first possibility to 
be thought of is extra-uterine pregnancy and its frequent 
sequel, retro-uterine hematocele, which, after the tubal 
sac has ruptured, discharges its contents into Douglas' 
pouch, and there forms a tense elastic tumor behind the 
uterus and in apposition with the posterior vaginal vault. 
The tumor of a dilated bladder in retroflexion and in- 
carceration of the uterus, subserous polypoid myomata, 
uterus bicornis, movable spleen and floating kidney, 
splenic tumor and hydronephrosis, echinococcic and bilat- 
eral ovarian tumors are also to be mentioned as possible 
sources of error in diagnosis. 

Treatment — As ovarian tumors per se demand re- 
moval much more than uterine myomata, and as their 
presence during gestation may give rise to complications 
which it is impossible to foresee (23 per cent, maternal, 
39 per cent, fetal mortality), their extirpation during 
pregnancy is indicated in every case and in every month, 
although preferably in the beginning, irrespective of the 
existence or absence of complications. Even double 
ovariotomy rarely brings on an abortion. Operation is 
contra-indicated only w^hen the child has reached the 
stage of viability (the thirty-fourth week), and no further 



TUMORS. 189 

complications are expected to arise from the tumor, 
especially when the parents are very desirous that the 
child should be preserved alive. The operation should 
not be attempted if the tumor is situated between the 
layers of the broad ligament, because the danger of 
hemorrhage is increased by the existence of pregnancy 
and the operation would be more dangerous than labor 
itself. In the case of small tumors within the true 
pelvis an attempt at reposition should be made, avoiding 
any rough manipulations on account of the danger of 
tearing the walls of the tumor. 

Puncture is inadmissible on account of the danger of 
infection. 

Induction of abortion or premature labor is adapted 
only to exceptional cases ; thus, in tumors in which reposi- 
tion is impossible on account of adhesions in all directions 
within Douglas' pouch, or on account of their intraliga- 
mentary situation, or which are of such a fibrous con- 
sistency that flattening is impossible. 

(c) Cancerous Growths of the Cervix and of the Vaginal 
Vault. — Cancer of the uterus is not a very rare complica- 
tion of pregnancy, and when it is present bodes very ill 
for both mother and child. The tumor itself grows very 
rapidly. The consequences are twofold. 

Either the tumor, which is still rigid, altogether pre- 
vents the expulsion of the ovum in premature labor, or 
delays its escape so long that ulcerations are produced, 
which sometimes perforate into the bladder, and it be- 
comes necessary to remove the fetus piecemeal ; the rigid 
tissues may prevent tlie veins from contracting and thus 
give rise to air-emboli at the site of the ulcerations, or 
else the tissue alteration gives rise to hemorrhages and 
separation of the friable cancerous tissue. Carcinomata 
situated high up in the cervix lead to abortion, or, by 
secondary disease, to changes in the placental or fetal 
tissues and premature expulsion of the ovum. In addi- 
tion, the force of the labor-pains is diminished and there 
is a greater danger of hemorrhage on account of the 



190 THE PATHOLOGY OF PREGNANCY. 

changes in the tissues of the utems, or ulcerations are 
produced in the softened lacerated portions, especially in 
the cervix (Fig. 110) and in the vaginal vault. Finally, 
there is danger of septic endometritis and nietrophlebo- 
thrombosis. 

Breech presentations are more apt to be produced in 
premature labors. 

The diagnosis from the decomposing remains of de- 
cidual tissue after an abortion, and from decomposing 
myomata and condylomata of the vaginal vault, is based 
on the demonstration of cancerous tissue and the charac- 
teristic nests in the portions removed for examination. 

The treatment should be directed solely to the relief 
of the mother from her disease ; hence, the possible methods 
of procedure are : 

(1) In the first half of pregnancy (Olshausen) imme- 
diate total extirpation of the entire uterus through the 
vagina, 

(2) Later, as long as the fetus is not viable, evacuation 
of the amniotic fluid and removal of the ovum, if neces- 
sary, by opening the anterior wall of the uterus and 
particularly of the cervix (Pfannenstiel and Reckman), 
followed immediately by total extirpation. 

(3) After the thirty-second week : Cesarean section if 
the cervical canal cannot be sufficiently dilated by deep 
incisions (one long incision through the anterior wall, 
otherwise delivery per vias naturales and vaginal extirpa- 
tion) ; this to be followed by supravaginal amputation and 
subsequent removal of the cervix through the vagina. 

(4) In inoperable cases the life of the mother is to be 
preserved as long as possible in order to save the life of 
the child. Proliferation and ulceration are to be checked 
by means of the thermocautery and injections of arsenic 
and alcohol. These measures seldom produce abortion. 

If premature labor occurs in an inoperable case, Porro's 
supravaginal amputation of the body of the uterus is to 
be performed, the stump being left outside the peritoneal 
cavity to prevent decomposition. 



ECTOPIC GESTATION. 191 

? 17. ECTOPIC GESTATION.— PLACENTA PR/EVIA. 
(A) ECTOPIC GESTATION. 

(a) Tubal Pregnancy. — In by far the greater number of 
ectopic gestations the ovum develops ^vithin the tube, 
usually in its middle and in the dilated portion or ampulla. 
From the middle portion the fetal sac may push its way 
in between the layers of the broad ligament and form an 
intraligamentary pregnancy. An intraligamentary gesta- 
tion due to rupture of the sac is known as grossesse sous- 
periton eopelvien ne. 

An impregnated ovum often lodges in a tubo-ovarian 
cyst or in diverticula of the tubes. If the egg becomes 
arrested at the fimbriated extremity a tubo-abdominal 
pregnancy usually results. 

In all these cases the fetal sac can be diagnosed as a 
pedunculated tumor (Fig. 112). 

If the ovum lodges in the isthmus of the tube an inter- 
stitial tubo-uterine gestation is produced (Fig. 117). It 
is distinguished anatomically from the above-mentioned 
tubal pregnancies by the fact that the round ligament lies 
to one side and the gestation-sac pushes its way into the 
uterus. Both tubal orifices are occluded in these cases. 
As the isthmus is very unyielding these gestation-sacs 
rupture in almost every instance ; rarely the ovum may be 
expelled into the cavity of the uterus. 

In a tubal pregnancy the gestation-sac is composed of perito- 
neum, the muscular layer of the tube, tubal decidua vera and 
circumflexa— which latter, if present at all, only partially encircles 
the ovum — the fetal chorion, and amnion. 

The decidua vera is formed from the stroma of the tubal mucosa ; 
the cylindrical epithelium is cast off, there is a proliferation of 
large cells and the papillae of the stroma are converted into decidua 
consisting of a newly formed reticular layer of tissue into which 
the chorionic villi penetrate. The intervillous circulation of 
maternal blood is occasionally established by the second month, 
but there is never a very intimate interlacement of fetal villi with 
the vascular prominences of the decidua in the serotinal zone. 
The danger of rupture arises from the fact that the muscular layer 
does not hypertrophy. In interstitial tubo-uterine pregnancy the 



192 THE PATHOLOGY OF PREGNANCY. 

Fig. 111. Gestation in the Rudimentary Horn of a Uterus Unicornis 

(after total extii'patiou, by Kelly, of Baltimore). — As the rudimentary 
horn is shut off from the uterine cavitj'- and the corpus luteum is found 
in the ovary of the opposite side, it is evident that intraperitoneal trans- 
migration of the ovum has taken place. 



decidua is very thin, so that the villi dip into the muscle-bundles 
and penetrate into the venous capillaries. 

The uterine mucosa also becomes converted into a 
decidua by the proliferation of large cells, the process 
being accompanied by a simultaneous increase of the 
entire organ both in length and in breadth. This uterine 
decidua is usually expelled between the second and fourth 
months with profuse hemorrhages, the muscular layer of 
the uterus also becoming hypertrophied (Figs. 15, 67, a 
and b). 

The superficial layer is not covered with epithelium ; the lumen 
of the glands, which are also deprived of epithelium, is narrowed 
down to a minimum while the capillaries are much dilated. In 
the deeper layers the gland-ducts are covered with several layers 
of epithelium. 

The diagnosis in most cases is exceedingly difficult, 
especially during the first months. 

The expulsion of decidua which we have just mentioned 
is an important sign and justifies the introduction of a 
sound into the uterine cavity, which, as has been explained, 
will be found enlarged in every direction and empty. The 
surface which was in contact with the uterine wall shows 
the openings of the glands between irregular fissures, 
while on the other side, looking toward the cavity of the 
uterus, the openings are found in a closer mesh work, 
resembling latticework (Fig. 67, a and h). 

By a careful combined examination the presence of a 
tumor distinct from the uterus is made out, and if the 
gestation-sac is situated in the free tubal extremity the 
tumor will be pedunculated. If the tumor is soft and 
elastic, the child in all probability is still alive ; if, on the 
other hand, hard nodular areas can be felt, the fetus is 
dead, and it is possible to palpate the extravasation which 



ECTOPIC GESTATION. 193 

takes place into the fetal membranes and is accompanied 
by a diminution of the amniotic fluid. 

If the idea of pregnancy has been entertained to begin 
with, the examiner is struck by the unexpectedly early 
rising of the gravid portions above the symphysis, and 
on auscultation the diagnosis may be confirmed by hear- 
ing the fetal heart-sounds in that area. The subjective 
symptoms are much intensified and the fetal movements 
in the fifth month occasion the woman great pain. 

From the fourth to the fifth months various portions of 
the fetus can be distinctly palpated. 

A normal nterine pregnancy may be complicated with 
extra-uterine gestation ; extra-uterine pregnancy on both 
sides and extra-uterine twin pregnancy have even been 
observed. The diagnosis of rupture of the gestation-sac 
is based on all the symptoms of internal hemorrhage with 
violent shock and collapse. After the third month rup- 
ture is especially to be dreaded on account of death from 
internal hemorrhcige. The retro-uterine hematocele is 
felt like a tense tumor behind and by the side of the 
uterus. In some cases rupture takes place without a 
marked liemorrhage, and the gradually escaping ovum 
has time to attach itself by one pole to the serosa and 
establish a new blood-supply. 

Differential Diagnosis. — The menstrual history aids 
in the differentiation from ovarian cysts, subserous 
fibroma, and pelvic abscess (fever) ; retroflexion of a 
gravid uterus (§ 15) is always attended Avith marked 
ischuria, which is absent in ectopic pregnancies, not to 
mention ru])ture of the amniotic sac and the anterior dis- 
placement of the portio vaginalis and thinning of the 
anterior lip of the os, which we observe in the former 
condition. 

Among the anatomical causes of tubal pregnancy, the 
most important is gonorrheal alteration of the cylindrical 
epithelium. 

The cells become swollen and lose their cilia. In addition, the 
inflammatory proliferation of the papillary stroma gives rise to an 

13 



194 THE PATHOLOGY OF PREGNANCY. 

Fig. 112. Tubal Pregnancy on tlie Right Side ; Left Lateral Displace- 
ment of the Uterus ; Corpus Luteum Verum on the Left Side. — Trans- 
migration of the ovum. 

Fig. 113. Ruptured Tubal Gestation-sac ; child in Douglas' cul-de- 
sac; adhesive peritonitis leading to kinking of the right tube. Eight 
lateral displacement of the uterus (original drawing from a specimen in 
the Munich Gynecological Clinic). 



interlacing mass of excrescences, the minute cleft-like interstices 
of which are filled with secretion and partially desquamated epi- 
thelium. The connective-tissue growth which accompanies the 
deeper interstitial inflammation destroys the contractility of the 
muscularis and thus the further progress of the ovum is arrested. 

Coarse primary alterations may be causative in pre- 
venting the passage of the ovum, as, for instance, when 
the Fallopian tube is constricted or acutely flexed by ad- 
hesions in localized peritonitis ; another cause is found in 
the congenital malformations sometimes occurring in the 
tube in the form of marked convolutions (Freund). 

The same effect may be produced by tuberculosis with 
cheesy degeneration as by severe gonorrheal salpingitis. 
Uterine polypi blocking the orifice of the tubes, or similar 
tumors and small myomata in the tube itself (salpingitis 
nodosa of the uterine portion of the tube), may prevent 
the entrance of the ovum into the uterine cavity. Emo- 
tional disturbances, even within the sphere of sexual life, 
and extra-uterine transmigration of the ovum may, in 
addition, prevent the impregnated ovum from following 
its normal path (Figs. Ill and 112). In such cases the 
condition is usually preceded by total or at least long- 
protracted sterility. 

The results of ectopic gestation are as follows : 

1. Pregnancy may go on to term and the fetus die 
unless it is delivered by means of a celiosalpingotomy. 

2. Labor-pains come on and the ovum is expelled (born) 
into the abdominal cavity through the fimbriated ex- 
tremity (tubal abortion, Fig. 116). 

3. Rupture of the gestation-sac either into the abdom- 
inal cavity (Fig. 113) or between the layers of the broad 
ligament. 



Tab. 53. 




Fig. 112. 




Fig. 113. 



ECTOPIC GESTATION. 195 

4. Tlie cliikl may be expelled into the uterine eavity and 
born in the natural way (in interstitial pregnancy, Fig. 117j. 

0. Death of the fetus on account of placental disease : 
extravasations beneath the chorion, myoma, hydramnios. 
The same conditions may produce monstrosities. 

When rupture takes place the woman goes into sudden 
collapse as the result of shock and hemorrhage. The 
child usually dies at once. The mother then has a chill 
and the milk begins to trickle from the enlarged mammary 
glands. If rupture takes place early, a retro-uterine he- 
matocele remains (see Atlas of Gt/necoiof/j/) ; the placenta 
mav be entirely absorbed, and the hematocele may later 
undergo suppuration or decomposition. 

In very rare cases the child may continue to grow- 
within the abdominal cavity without any gestation-sac. 
Such cases, known as tubal abortions, lead to secondary 
abdominal pregnancy (Fig. 113). 

(6) Abdominal Pregnancy. — The course is the same in 
the primary as in the secondary form, to which we have 
refei'red in the foregoing paragraph. The possibility of 
a primary abdominal pregnancy taking place is incon- 
trovertibly proven by Schlechtendahl's case, in which the 
gestation-sac became encysted in the region of the spleen ; 
although many cases diagnosed anatomically as abdominal 
jiregnancy prove to be primarily derived from the epithe- 
lium of the fimbriae or to be nothing more or less than 
tubal gestation-sacs. 

The decidua is formed from the peritoneum, usually from the 
])osterior surface of the uterus, and fibrinous bands re-enforce the 
walls of the gestation-sac. which may attain a thickness of from 
f to f in. (1 to 1^ cm.). ^Muscle-fibers derived from the subserous 
tissue contribute the muscular element. Fibers with transverse 
striations have even been found, and I may remark in this con- 
nection that such fibers have often been found at the placental 
site in the uterus in an ordinary uterine gestation. In all ectopic 
gestations the thickness of the w^alls, and, therefore, the possi- 
bility of rupture, depends on the state of the muscularis. Fre- 
quently there is an entire absence of maternal tissue in a consider- 
able portion of the periphery of the ovum ; occasionally a decidua 
reflexa appears to be formed. 



196 THE PATHOLOGY OF PREGNANCY. 

Fig. 114. Perforation of a Tubal Sac into the Bladder and Rectum 
by Fetal Bones, the fetus haviug undergone absorption. Anteversion 
of the uterus. 

Fig. 115. Ovarian Pregnancy. — Adhesive peritonitis ; kinking of left 
tube. 

Fig. 116. Abdominal Pregnancy. — Adhesive peritonitis. 

Fig. 117. Interstitial Extra-uterine Pregnancy. 

Figs. 114-117. Original drawings, after specimens from the Munich 
Gynecological Clinic. 

As regards the diagnosis I can only refer to that of a 
tubal pregnancy. 

Course. — Abdominal gestation may end in various 
ways : 

1. The child lives to term and labor-pains make their 
appearance. 

2. Premature labor-pains, separation of the placenta, 
hemorrhage into the placenta, death of the fetus. 

3. After death the fetus undergoes the same changes 
in this variety as it does in tubal and ovarian pregnancies. 
These changes are as follows : 

(a) Absorption, the rapidity depending on the number 
of septic micro-organisms present. The amniotic fluid 
and the tissue-juices are absorbed, the fetus and fetal 
membranes coalesce, the mass becomes organized by the 
proliferation of granulation-tissue as far as the bones, or 
septic peritonitis results. 

(6) Expulsion, with or without absorption, by ulcera- 
tion through the bladder, the rectum (Fig. 115), the 
vagina, or the anterior abdominal wall, the ulceration 
resulting from the action of micro-organisms within the 

tubes. 

(c) Calcification beginning in the peritoneal bands (usu- 
ally in the absence of septic micro-organisms). It may 
be of various kinds : 

(«) Lithokelyphos, or calcification of the membranes, 
the child being"^ completely preserved within this calcified 
envelope.^ 

1 As, for instance, in the cases of Virchow and Kiichenmeister, and the 
London and Langensalza " petrified infants." 



Tnh. r,.',. 




Fig. 114. 




Fig. 115. 



Tiih. 55. 




Fig. 116. 




Fig. 117. 



ECTOPIC GESTATION. 197 

ifi) CalcificatioD of the coutiguous surface of the fetus 
— lithokelyphop?edion/ 

(y) Iniprcgnatiou of the fetus with lime-salts with 
entire absence of the fetal membranes — lithop^dion ; tlie 
internal organs are only partially involved in the cal- 
cification ; they undergo a fatty change and are converted 
into lime-soap, resembling ambergris.^ 

((/) The fetus remains as a skeleton. 

(c) Ovarian Pregnancy. — This is the rarest form of all. 
Impregnation takes place : 

(1) In the follicle, because the rupture is too small for 
the escape of the ovum. 

The chorion dips into the surrounding stroma, the 
decidua is contributed by the zona granulosa of the 
Graafian follicle, assisted by the ovarian stroma. The 
stalk of the tumor is formed by the ovarian ligament. 

(2) The ovum becomes impregnated primarily in the 
follicle and the gestation-sac, embedded in masses of fib- 
rin, projects into the abdomen forming an ovario-abdominal 
gestation. 

(3) Tubo-ovarian pregnancy results if a congenital or 
acquired ovarian tube is present (from perisal])ingitis and 
kinking of the tube, cf. § 1). 

(4) The ovum is inij^regnated in a tubo-ovarian cyst. 
A small cyst from a partially degenerated ovary ruptures 
into a tube and hydrosalpinx results. 

Ovarian gestation has been observed once or twice in 
an inguinal hernia containing an ovary. The fetus rarely 
attains maturity in this form of ectopic gestation. 

Treatment of Ectopic Gestation. — The most 
favorable termination is premature rupture of the gesta- 
tion-sac in the first two months, followed by absorption 
of the fetus, or early mummification and petrifaction if 
the fetus is too large to be absorbed ; but even under these 
conditions 25 per cent, of the cases terminate fatally. 
After the second month the mother's life is threatened by 

* For instance, the petrified infants at Leinzell and Pont-a-Mousson. 
2 The petrified infants at Heidelberg, Liibben, and Toulouse. 



198 THE PATHOLOGY OF PREGNANCY. 

hemorrhages, and the fetus, on account of its greater size, 
is more apt to undergo decomposition. 

The question of treatment is still a very difficult one to 
decide. The ideal procedure — inaction until the child 
has come to maturity and preservation of both mother and 
child — is a very risky undertaking in view of what has 
been said above and of our modern methods of operation. 
The indications are about as follows : 

(1) During the first three months injection of gr. ss 
(0.03 gm.) of morphin, once repeated, into the amniotic 
sac may be tried under certain conditions, without aspirat- 
ing the amniotic fluid and under strict antiseptic precau- 
tions, with a view of bringing about the death of the fetus 
(v. Winckel). 

(2) If the fetus continues to grow in spite of this, or 
if the subjective symptoms become violent or alarming — 
and this applies especially to obscure cases — an abdominal 
section should be made. Opening of the vaginal vault and 
pouch of Douglas is permissible only when the tumor is 
small, distinctly pedunculated, and non-adherent. 

(3) In advanced ectopic gestations the fetus may be 
allowed to go on to viability only in case the marriage has 
been sterile and a living child is earnestly desired. The 
mother should then be confined to bed. Otherwise im- 
mediate celiotomy is indicated ; or, 

(4) If the fetus is dead, it should be removed some time 
later (preferably six months) by means of a celiotomy. 

(5) If rupture has taken place, celiotomy may be per- 
formed if the woman is not in too profound a condition 
of collapse and rupture has occurred only a few hours 
previously ; if the symptoms of hemorrhage are too 
severe or the shock is too profound, the patient must not 
be deprived of the extravasated blood. The treatment 
then consists of absolute rest, opiates, antispasmodics, the 
application of a sand-bag to the abdomen, elevation of 
the pelvis, and subcutaneous, rectal, and intravenous in- 
jections of decinormal salt solution ; the fetus being re- 
moved later. 



PLACENTA PREVIA. 199 

If the accident has occurred some time previously, and 
there is no immediate danger, an expectant policy may be 
adopted. 

((i) If, during the later months, the gestation-sac can- 
not be removed, it is to be fixed extraperitoneally into the 
abdominal wound and tamponed. 

(7) In suppuration of the hematocele incision through 
the vagina and drainage are indicated. 

(B) PLACENTA PREVIA. 

If the attachment of the ovum to the uterine wall is 
abnormal, so that the decidua serotina is inserted in the 
lower uterine segment from the very beginning of preg- 
nancy (with the exception of a few cases in which the 
decidua reflexa, which is usually devoid of glands and 
vessels, is traversed by loops of blood-vessels), the condi- 
tion kno\vn as placenta prsevia results. As a result of the 
uterine contractions, the lower uterine segment undergoes 
marked passive distention even during pregnancy, but 
particularly during labor. The traction thus exerted 
tends to loosen the placenta, which then either blocks the 
entire internal os in the form of placenta prsevia centralis 
(Fig. 13 in the text), or the edge projects over the orifice, 
when the condition is know^n as placenta prsevia mar- 
ginalis (Plate 23, and Fig. 14 in the text). Depending 
on the variety of placenta previa present we have, after 
the seventh month in placenta prsevia centralis, after the 
eighth month in placenta prsevia lateralis, after the 
ninth month in placenta prsevia marginalis, as an im- 
portant diagnostic sign, hemorrhage due to injury of the 
placental vessels, and, rarely, of the fetal vessels within 
the chorionic villi or even to laceration of the placenta. 
If this accident occurs during pregnancy, a placenta 
pr^evia centralis is converted into a placenta prsevia siic- 
centuriata (Fig. 13 in the text) ; if, on the other hand, 
one lobe of the placenta is torn away during labor, the 
placenta previa centralis is converted into a placenta 
pr^evia lateralis. 



200 



THE PATHOLOGY OF PREGNANCY. 



The hemorrhages Avhich not infrequently occur in the 
first half of pregnancy are explained partly by the uterine 
contractions, partly by the loosening of the villi from the 
attenuated lower uterine segment, particularly when the 
placenta is much flattened. 

The abnormal insertion of the placenta takes place at 
the very beginning of gestation. Thus, Hunter and 
Gottschalk have found ova inserted at the internal os as 
early as the first month. 

(a) The uterine cavity may not be adapted to the re- 
ception of the ovum. This is the case in fibromyoma ; 




Fig. 13. — Placental infarct. 



Fig. 14. — Placenta prsevia. 



in malformations and malpositions of tlie uterus (uterus 
unicornis, bicornis, or deep insertion of the oviducts) ; in 
defective involution and consequent dilatation of the 
cavity, as when the woman is allowed to get up too soon ; 
in relaxation of the uterine wall due to several rapidlv 
succeeding pregnancies, a condition to which older women 
in their second or third pregnancies are particularly 
liable; or in cases of abnormally wide uterine cavities 
due to chronic catarrh (metritis) — in all of which condi- 
tions there is an incomplete decidua formation owing to 
disease of the mucous membrane. 



PLACENTA PREVIA. 201 

(6) The condition of the lower uterine segment itself 
may be such as to favor a low insertion near the internal 
OS. This occurs in cancer of the cervix, because, as in 
endometritis, the decidua reflexa is prevented by the can- 
cerous secretion from undergoing liquefiction ; there is a 
marked increase in the vascular supply, especially in the 
fold of the reflected portion, causing the chorionic villi 




Fig. 15. — Velamentous insertion of tlie placenta. 

topersist in that region. It occurs also in old lacerations 
of the cervix. 

(c) Lastly, when the decidua serotina covers an ab- 
normally large area ; hence, the condition is especially 
liable to occur in twin pregnancies. 

We must also emphasize the frequent occurrence of 
velamentous insertion (Fig. 15 in the text), placenta suc- 
centuriafa, marginata, membranacea, and of placental 
infarcts (Fig. 13 in the text), in combination with placenta 
praevia (Figs. 96 and 101). 

It is evident, therefore, that disease of the endometrium 
and its inability to nourish the ovum are the most im- 



202 THE PATHOLOGY OF PREGNANCY. 

portant factors in the etiology. Ahlfeld observed in cer- 
tain puerperal uteri the absence of a soft, smooth mucous 
membrane and of a true placental site, that is, the 
thrombosis was less marked. 

These anatomical findings explain why multiparse and 
elderly primiparse and women of the poorer classes, with 
whom the element of hard work enters into the question, 
are particularly liable to placenta prsevia, and often suffer 
from the condition repeatedly. 

The diagnosis rests chiefly on the occurrence of inter- 
mittent hemorrhages during pregnancy. The anatomical 
findings are only occasionally of value. It may be possi- 
ble to palpate the low insertion of the placenta through 
the abdominal walls, or the soft, doughy consistency of the 
supravaginal portion of the cervix may be noticed, or it 
may be impossible to palpate the fetal parts through the 
vagina, etc. In the differential diagnosis it is to be 
remembered that similar hemorrhages occur in hydatid 
mole, in which condition, however, no fetal parts can be 
palpated and the size of the uterus does not correspond to 
the period of pregnancy. 

Course. — In a great number of cases the ovum is 
aborted (Dohrn). The internal os may remain closed until 
the time of parturition, so that a lower uterine segment 
cannot be formed and traction on the placenta is impossi- 
ble. In such a case there are no hemorrhages during 
pregnancy. 

If the integrity of the cervix is not preserved and the 
supravaginal portion protrudes with the internal os, hemor- 
rhage occurs early and alterations take place in the 
placenta. The fetus may be asphyxiated by the hemor- 
rhage, or a small lobule of the placenta is torn away and, 
after becoming emptied of blood, undergoes atrophy. 

During labor, especially if it is premature, there is 
great danger of lacerations in the undeveloped portion of 
the cervix, which has a tendency to stricture formation ; 
hence, an accident is particularly liable to occur during 
operative interferences. 



PLACENTA PREVIA. 203 

After labor-pains have made their appearance the 
hemorrhage is increased during the pauses and the lower 
portion of the placenta is detached by the uterine con- 
tractions. The hemorrhage is often increased by lacera- 
tions of the fetal vessels in marginal and velamentous 
insertions, as the resulting stasis leads to engorgement and 
separation of the lowest cotyledons and further hemor- 
rhage. Although the labor-pains momentarily compress 
the uterine vessels they are greatly diminished in strength, 
partly because labor is premature, partly on account of 
the extreme teuuity of the muscular layer in the lower 
uterine segment and because the most effective stimulus — 
the descent of the amniotic sac — is wanting, partly also 
because a vicious circle is established, and the loss of 
blood in turn diminishes the contracting power of the 
muscularis. 

On account of the gaping of the vessels there is danger 
of air entering the circulation. Again, the atony of the 
placental site leads to further hemorrhages, which are 
arrested in the end only by the reversed arterial supply 
of the lower uterine segment from the upper thicker 
muscular layers, as was described in § 8. 

As a result of deviation of the head in the spherical 
lower portion of the uterus abnormal presentations occur, 
and occasionally prolapse of the placenta takes place 
before the child is delivered. Retention of fetal mem- 
branes is a common accident. Death occurs in 25 per cent, 
of all the cases, either from hemorrhage or from infection 
due to the necessary manipulations when the cervix is 
only partially opened (lacertions and secondary anemia). 

The treatment is principally directed to the control 
of the hemorrhage. Firm aseptic tamponade of the cervix 
and vagina with iodoform gauze or with Barnes-Fehling's 
violin-shaped colpeurynter, the placenta pr^evia centralis 
being perforated ; dilatation of the os and version (after 
Braxton Hicks — see the author's Atlas of Labor and 
Operative Obstetrics) are always to be performed when the 
entire cervical canal admits two fingers, but without sub- 



204 DEFORMITIES OF THE PELVIS. 

sequent extraction, one foot being brought down to act as 
a tampon ; or, without version, the uterus may be tam- 
poned with iodoform, nosophen, or silver gauze until the 
OS is completely dilated ; analeptic remedies (antispas- 
modics), ergotin, and, if necessary, subcutaneous or rectal 
injections of 0.6 per cent, salt solution may be given. 
In longitudinal presentations the hemorrhage may be 
stopped by rupturing the bag of waters. In postpartum 
hemorrhage due to atony resort may be had to ergotin, 
bimanual rubbing and kneading of the uterus, which 
should be anteflexed, either with one finger in the uterine 
cavity or — if it can be done at once and for the purpose 
of combining massage — from without, followed by tam- 
ponade of the uterine cavity after Diihrssen. The most 
effective measure is to draw down the uterus in front of 
the vulva and seize the portio vaginalis with a pair of 
stout Muzeux forceps. The kinking of the uterine ves- 
sels, which is thus effected, directly diminishes the hemor- 
rhage and acts indirectly to produce contraction on account 
of the accumulation of carbon dioxide. Not infrequently 
the placenta has to be removed with the hand introduced 
into the uterus. 



CHAPTEE YI. 



DEFORMITIES OF THE PELVIS AND THEIR IN= 
FLUENCE ON PREGNANCY AND LABOR. 

I i8. GENERAL REMARKS ON THE DIAGNOSIS AND 
TREATMENT OF DEFORMED PELVES. 

For the diagnosis the reader is referred to § 3. The 
effect of skeletal deformities on the pelvis is to be borne 
in mind and careful palpation of the pelvic cavity must 
never be neglected.^ 

1 Kyphosis in the lower portion of the column suggests a funnel-shaped 
pelvis. Scoliosis and a limping gait point to an oblique pelvis, while the 
characteristic rachitic deformity with joint enlargements and pendulous 
abdomen should arouse the suspicion of a flat pelvis. 



GENERAL REMARKS ON DEFORMED PELVES. 205 

Both internal and external asymmetry can be determined 
by inspection and palpation. In rachitic pelves the dis- 
tance between the spines is equal to, or greater than, the 
distance between the crests. In obliquely contracted 
pelves one iliac bone is often higher than the other. In 
equally contracted pelves the interspinous distance is 
equal to, or less than, a span from the thumb to the little 
finger (8f in. = 23 cm.). Internally we determine the 
configuration and width of the linea terminalis ; the posi- 
tion of the promontory, especially with relation to the 
superior strait ; the condition of the cartilage in the 
symphysis (cf. § 20, Xo. 12) ; and the inclination of the 
symphysis (more vertical in rachitic pelves). We also 
determine whether the promontory and symphysis are in 
the same sagittal plane or not (oblique pelves). We first 
palpate the tuberosities and the spine of the ischium, 
ascertain the width of the pubic arch (the distance between 
the former is diminished in funnel-shaped pelves, the 
latter is greater in rachitic pelves), and examine the coc- 
cyx for a possible anterior luxation. Exostoses are to be 
sought for in the sites of predilection mentioned in § 20, 
No. 12. The history of former labors is also of great 
importance. 

By pelvimetry we detect general contractions of the 
perimeter of the pelvis or diminution of single diameters : 
the true conjugate of the oblique diameters or the trans- 
verse diameter. The measurements of the pelvic outlet 
are also ascertained. 

If the diminution of the conjugate is due to rachitis, 
we must subtract more than the usual number of centi- 
meters from the diagonal conjugate on account of the more 
vertical position of the symphysis ; that is, instead of |- in. 
(1.5 cm.) we subtract from -f- to 1 in. (2 to 2.5 cm.). (See 
§§ 3 and 4, the relations between the external conjugate 
of Baudelocque in flat rachitic pelves and the influence of 
the woman's position on pelvic measurements, Walcher's 
position ; also the value of external measurements in the 



206 DEFORMITIES OF THE PELVIS. 

determination of the size of the superior strait, especially 
in contracted pelves ; cf. § 3.) 

The rigidity of the pelvic joints and the compressibility 
of the fetal skull during labor have been referred to in § 7, 
under " Configuration of the Skull. '^ A pelvis is con- 
sidered contracted in the obstetrical sense not only when 
it constitutes an obstacle to labor, but when it leads to 
abnormal presentations ; Litzmann assumes as a limit for 
the true conjugate 3 J to 4 in. (9.7 to 10 cm.). 

Anomalies in shape and position of the uterus and of 
the fetus during pregnancy also interfere with the proper 
entrance of the fetus into the true pelvis. 

The duration of labor is increased by half; in 56 per 
cent, of all the cases the head does not engage in the true 
pelvis until the external os is completely dilated. As a 
result the bag of waters frequently ruptures prematurely, 
that is, before the os is completely dilated. In flat pelves 
there is a laro^e amount of amniotic fluid in front of the 
head and this permits prolapse of the cord or of one of 
the extremities, and leads to further anomalies in the 
attitude and presentation of the child. 

The force of the labor-pains is not diminished a priori, 
but they may become weaker secondarily ; at least, their 
effect may be diminished because some of the muscle- 
fibers go into a state of partial spasm from failure of the 
head to descend or subsequent fixation of the cervix 
between the head and the pelvic wall. Premature dis- 
charge of the amniotic fluid — in which case the dilatation 
of the OS is accomplished with much more pain to the 
mother by the pressure of the head, and edema, lacerations, 
and contusions are apt to result — abnormal positions of the 
child, and, finally, old scars in the vaginal vault may also 
impair the strength of the labor-pains. The lower uterine 
segment is very much distended, hence, pressure-necrosis 
and rupture or perforation are very apt to occur. 

The joints of the pelvis may be torn apart either by 
raising the handles of the forceps too early, especially if 
the operator indulges in forced rocking movements from 



GENERAL REMARKS ON DEFORMED PELVES. 207 

side to side, or, more rarely, when tlie head lias reached 
its limits of compression and accommodation to the pelvic 
cavity. Among the predisposing factors to this accident 
are primary inflammations and snppurations, osteomalacia, 
caries, tumors, and, in funnel-shaped pelves, the leverage 
Avhich the descending rami of the pubis exert on the 
symphysis during the passage of the head. 

The diagnosis of separation is made by feeling the 
bones give way and by the presence of constant pain and 
abnormal mobility. The bones reunite with or without 
the application of a binder. The latter consists of two 
towels passing around the region of the sacrum, crests, 
and spines, tied together above the symphysis (Ahlfeld). 
Artificial separation of the symphysis or symphysiotomy 
has lately come into vogue again to prevent laceration of 
the perineum, and has been attended with some success, 
but it should be attempted only in hospitals. 

Injuries to the child consist in disturbances of the pla- 
cental circulation, and, therefore, of the respiration, by 
the powerful contractions with which the uterus attempts 
to overcome the obstacle presented by a contracted pelvis. 
In some cases the uterus may go into tetanic contraction. 
As a result of long-contined pressure, especially if the 
amniotic fluid is evacuated early, we have edema, bruises, 
necroses, depressions, and fissures and fractures of the 
skull. The overlapping of the bones of the skull may be 
excessive (cf. Figs. 130-1 33a, and § 20, under No. 3a). 
Such injuries lead to the formation of cephalhematomata 
or of subdural extravasations. Fracture may also occur 
at the base of the skull or in one of the cervical vertebrae. 
The size of the fetal head and body must be determined 
by bimanual examination (see § 2), remembering that in a 
multipara the resistance offered by the maternal soft parts 
and the size of the head are greater than in primiparse. 
An important procedure, both from a diagnostic and from 
a therapeutic point of view, is to exert moderate pressure 
on the head once a week for from one to one and one- 
half minutes, if possible as early as the twenty-eighth to 



208 DEFORMITIES OF THE PELVIS. 

the thirtieth Aveek, so as to force it to enter the superior 
strait. 

In the matter of treatment it is to be remembered 
that : 

(1) According to v. AVinckel, seven-tenths of all labors 
in contracted pelves are terminated without operative 
interference ; and, 

(2) That the most scrupulous asepsis is to be observed 
from the very first examination, even if the accoucheur is 
convinced beforehand that an operation will probably be 
necessary. The fissures and excoriations which are always 
produced are very liable to become converted into ulcer- 
ating surfaces covered with the semifluid, greenish exudate 
characteristic of septic invasion. The expectant treatment 
consists in carefully controlling the advance of the head 
and the strength of the labor-pains, that is, a primipara 
should be forbidden to bear down at all, and in every case 
abdominal pressure should be forbidden until the head has 
passed' the superior strait. The labor-pains may be regu- 
lated by the application of hot compresses, baths, mustard- 
plasters, and the administration of morphin, chloral 
hydrate, and chloroform. The woman should lie on the 
side on which the presenting part is felt. If the abdomen 
is pendulous it should be supported by means of a binder. 
The upper part of the body should also be supported until 
the head engages in the superior strait ; in some cases it 
may be necessary to put the woman into Walcher's posi- 
tion (see § 4). The diagnosis is finally confirmed and the 
treatment completed by the above-mentioned external 
pressure on the head. The general indications for opera- 
tion, as far as the pelvis is concerned, have been mentioned 
in § 20, under Xo. 2a, foot-note. The special indications 
will be found in the AUclh of Labor and Operative Ob- 
stetrics. 

If the head fails to descend and is still movable, or if 
it is impossible to convert a face presentation with the 
chin posterior into a vertex presentation, version is indi- 
cated if the child is alive and the true conjugate is not 



Tab. 56. 




Fig. 120 



LlUi. Anst F. Reichhold. Mujxch^ji. 



Tab. 57. 




Fig. 123. Lilh.An.s1 F. Reichhold,Munchm. 



CO 




PECULIARITIES OF DEFORMED PELVES. 209 

less than 2J or 3} in. (7 or 8 cm.). If, under the same 
conditions, the head has entered the pelvis and is immov- 
able, the forceps should be used. Embryotomy is indicated 
if the true conjugate is not less than 2f or 2J in. (6.5 or 
5.5 cm.) (see § 20, No. 2a, foot-note). If the contraction 
surpasses this limit it constitutes an absolute indication 
for Cesarean section. 

I 19. ANATOMICAL AND OBSTETRICAL PECULIARS 
TIES OF DEFORMED PELVES. 

Fig. 50 (Plate 25), Generally equally contracted pelvis (text, § 20, 
No. 1). 

Fig. 118. Flat non-racliitic pelvis (text, ^ 20, No. 2a). 

Fig. 119. Flat rachitic pelvis (text, ? 20, No. 3a). 

Fig. 120. Generally contracted flat rachitic pelvis (text, ^ 20, No. 36). 

Fig. 121. Flat rachitic jielvis of high degree (text, ^ 20, No. 3a). 

Fig. 122. Compressed rachitic pseudo-osteomalacic pelvis (text, § 20, 
No. 3c). 

Fig. 123. Compressed osteomala(;ic pelvis (text, § 20, No. 4). 

Fig. 124. Zone of Ossification in a Normal Epiphysis (microscopical) : 
1, hyaline cartilage; 2, zone of beginning proliferation of the cartilage; 
3, columns of cartilage-cells arranged in rows; 4, columns of enlarged 
cartilage-cells ; 5, first zone of calcification ; 6, layer of osteoblasts in 
first zone of ossification ; 7, fully developed cancellous tissue (spongiosa) ; 
8 and 9, blood-vessels in transverse and longitudinal section. 

Fig. 125. Zone of Ossification in a Rachitic Epiphysis (microscopical) : 
1, transition of normal hyaline cartilage to proliferating cells : 2, zone 
of cartilage-cells arranged in roAvs ; 3, cellulofibrous medullary spaces 
containing blood-vessels in the region of the proliferated and enlarged 
cartilage-cells; 4, island of calcified cartilaginous tissue; 5, columns of 
osteoid and fully developed calcified bone-tissue; 6, columns of osteoid 
tissue not containing lime-salts; 7, like 3, with the blood-vessel in trans- 
verse section. 

Fig. 126. Microscopical Section through an Osteomalacic Bone : 1, 
remains of calcified bone-substance; 2, decalcified bone-substance; 3, 
large medullary spaces due to the disappearance of bone-substance; 4, 
Haversian canals (text, ^ 20. Nos. 3 and 4). 

Fig. 127. Conical Abdomen (Spitzbauch), showing the area of dulness 
(from a case of polyhydramnion of Kiistner). 

Fig. 128. Pendulous Abdomen, first degree. 

Fig. 129. Pendulous Abdomen, second degree (^? 15c, 20, Nos. 3 and 4). 

Fig. 130. Cephalic Presentation at the brim in a flat rachitic pelvis 
in Nagele's obliquity. Second vertex presentation, or presentation of 
the anterior parietal bone (text, § 20, No. 3). 
14 



I 




210 



Tab. 60. 




Fig. 132. 

Lith.Anst E Reichhold. Miinchen. 



^ 




CO 

CO 



o 



Tab. 62. 




Fig. 134 




Fig. 136. 



Liih.Anst E Reirhhold, Munchen.. 



PECULIARITIES OE BEEOBMED PELVES. 211 

Fig. 131. Dia^am Shomng the Curve of tlie Sacrum in normal, 
rachitic, and osteumalacic pelves, with the changes iu tlie position of the 
symphysis. Presentation of the head as in the preceding figure, seen 
in sagittal section in a flat rachitic pelvis (text, § 20, Xos. 3 and 4). 

Fig. 132. Shows the Shape of the Skull described in Figs. 130 and 
131 : depression of the posterior parietal bone by the promontory, fract- 
ures, characteristic bulging of the anterior left parietal bone (text, § 20, 
No. 3). 

Fig. 133. Brow Presentation in a case of hydrocephalus with gener- 
ally and flat contracted pelvis. Complete rupture of the uterus resulted. 
The position shown in the figure corresponds to what was found at the 
autopsy. 

Fig. 133a. Hydrocephalus of Fig. 133. — See, also, illustration of the 
rupture in Figs. 1.52 and 1-53 (text. ^ 20, Xo. 1;. 

Fig. 1.S4. Infantile or Undeveloped, Funnel-shaped Pelvis, with oval 
superior strait and contracted outlet text. ^ 20. 5 7 . 

Fig. 51 (Plate 25). A Fetal Undeveloped, " Decubital" Pelvis, funnel- 
shaped (text, § 20, Xos. 56 and 8). 

Fig. 135. RacMtic-kyphotic, Funnel-shaped Pelvis, with symmetrical 
assimilation — so-called " intercalated vertebra": better. ''txansiTional 
vertebra,'' bilateral formatiou (text, 5 20. Xo. 11). 

Fig. 136. Kyphotic. Funnel-shaped Pelvis, with double promontory 
(text, § 20, Xo. 5c). 

Fig. 137. Asjomnetrical assimilation pelvis, not obliquely contracted. 
The lumbosacral "transitional vertebra" forms part of the sacrum on 
the left, and part of the lumbar vertebra on the right side (text, § 20, 
Xo. 11). 

Fig. 138. Double Promontory in Sagittal Section (text, § 20, Xos. 
5 and 11). 

Fig. 139. Obliquely Contracted Pelvis, due to rachitic scoliosis (Sfc) : 
the two lowest lumbar vertebrae indicate the compensatory direction 
(text, ^ 20, Xo. 6n). 

Fig. 140. Superior Strait of a Right Obliquely Contracted Pelvis, 
the left half representing ''dead space '" for the passage of the head 
(text, § 20, Xo. 6). 

Fig. 141. Right Obliquely Contracted Pelvis, due to ankylosis of the 
right hip following coxiti- text, ^ 2<:i. Xo. 6'7 . 

Fig. 142. Left Obliquely Contracted Pelvis, due to synostosis of the 
alae of the sacrum on tlie ris^Iit side 'text, § 20. 6b'. 

Fig. 143. Spondylolisthetic Pelvis text. ? 20. Xo. 10). 

Fig. 144. Robert's Transversely Contracted Pelvis text. ^ 20. Xo. 7). 

Fig. 145. Flat, Anteroposteriorly Contracted Pelvis, due to luxation 
of both femora backward and upward (after Schauta — text, §20, Xo. 8). 

Fig. 146. Transversely Contracted Oval Pelvis, due to double talipes 
varus ^after Schauta— text, i 20. Xo. S). 

Fig. 14T. Split Pelvis or Pelvis Flssa (after Schauta— text, § 20, X'o. 9). 



212 DEFORMITIES OF THE PELVIS. 

Fig. 148. Acanthopelys (spiny pelvis) in rachitis ; at the iliosacral 
articulation on the right (29) and at both iliopubic synostoses (30) (text, 
g 20, Nos. 3 and 12). 

Fig. 149. Exostosis as a result of fracture of the iliac bone (after 
V. Winckel— text. ^20, No. 4). 

Fig. 150. A Cystic Enchondroma, seen from above (Behm's case — text, 
§20, No. 13). 

(Original drawings from preparations in the Munich Gynecological 
Clinic: 133, 133a from the Heidelberg Gynecological Clinic ; 150 drawn 
from a cast ; 122 after K. Schroder ; 149 after v. Winckel ; 124-126 after 
Ziegler; 145-147 after Schauta). 

CLASSIFICATION AND DESCRIPTION OF DEFORMED 

PELVES. 

Generally Contracted Pelves. 

No. 1. — Generally equally contracted pelvis. — Varieties: 

No. \a. — Juvenile pelvis, seen usually in well-grown 
individuals (Fig. 50). 

No. lb, — Masculine pelvis, simple contracted, with 
heavy masculine bones. 

No. Ic. — Dwarf pelvis (pelvis nana). 

Etiology. — Arrest of development, without rachitis. 

Character istics. — These peh'es resemble the normal in 
shape and symmetry ; the bones are normal in thickness ; 
they represent, as a rule, a simple miniature of a normal 
pelvis. In some there is infantile arrest of development. 

In the infantile^ (No. la) the promontory is high and 
not very prominent, the sacrum straight, and the inclina- 
tion of the symphysis diminished. On the other hand, 
the transverse diameters are normal. The distance be- 
tween the posterior spines is increased. 

In the masculine pelvis the bones are extraordinarily 
thick and heavy ; tlie genitalia are often infantile. 

In the dwarf pelvis the bones are slender and fragile ; 
the proportions are normal ; tliere is a marked lateral 
curvature of the anterior surface of the sacrum. In the 
infantile variety the cartilaginous junctions between the 

1 This variety not to be confounded with the '' fetal or undeveloped " 
funnel-shaped pelvis. — Trans. 



Tab. 63. 




Fig. 137. 




Fig. 139. 



Lith . Ami E Retdihold, Miindim. 



Tab. 64. 




142. 



10 3b 



Fig. 143, 



35 

Fig. 144- 

Lith.Ansi F ReicMwld.Mundmi. 



Tab. 65. 




Fig.. 147. 



Ltth . Anst E ReidihoLd, Miinchen. 



Tab. 66. 




Fig. 148. 




Fig. 150. 



lith..Anst F Reichhold, Miindim. 



GENERALLY CONTRACTED PELVES. 213 

divisions of the sacrum and iliac bones persist. The 
sacral alie are narrow in proportion to the body of the 
vertebra. The promontory is flat. The transverse meas- 
urements are normal. 

No. Id. — Generally equally contracted rachitic pelvis. 

Etiology. — Rachitis. 

Characteristics.— AW the measurements are smaller, 
especially the distance between the spines. It differs 
from the juvenile pelvis by its angular, unsightly out- 
line (cf. Fig. 50), by the prominence of the crest of the 
pubis, by tlie rachitic form and position of the sacrum 
(see under "Rachitic Pelves^'), and by the increasing 
expansion at the outlet. Probably not so very rare as is 
usually stated. The relation between the spines and crest 
is normal ; promontory not prominent ; diagonal con- 
jugate shortened ; distance between the posterior spines 
increased — hence not rachitic — perimeter of the pelvis 
about 2|^in. (7 cm.) less. Even when all the diameters 
are shortened by f in. (2 cm.) there is not much more 
impediment to labor than usual. 

Diagnosis. — Conjugata vera between 3|- and 4J in. (9J 
and 10^ cm.) ; never less than 6^ in. (8 cm.) in juvenile 
pelves. 

Influence on Pregnancy. — Uterine displacements are 
rare because the lower portion of the fetus succeeds in 
entering the true pelvis tow^ard the end of pregnancy ; 
hence, also, cephalic presentation is the rule. 

Labor. — On account of the uniform resistance encoun- 
tered at the inlet the chin is brought nearer the chest, in 
other words, the head is strongly flexed (Roderer's ob- 
liquity). This is often combined with Solayres' obliquity 
or engagement in the oblique diameter. Advance of the 
plane (12| in. = 32 cm.) corresponding to the lesser ob- 
lique diameter of the fetal skull (3|- in. = 9.5 cm.) ; the 
lesser fontanel can be readily palpated. 

Presentation of the greater fontanel (i. e., occipito- 
frontal periphery — 13f in. = 34 cm. — corresponding to 
the occipitofrontal diameter — 4| in. = 12 cm.) or of the 



214 DEFORMITIES OF THE PELVIS. 

brow (Fig. 133) is very rare and most unfavorable, 
especially if the uterus is displaced to the right; hence, 
in such a case the woman must not be allowed to lie on 
her right side. 

In pelvic presentations, which are rare, the head is 
delivered in an analogous attitude of flexion. 

The progress of the head is very apt to become arrested 
(paragomphosis) ; labor-pains soon cease and pressure- 
necroses result. In rare cases the uterus may be ruptured. 
Eclampsia is extraordinarily frequent, owing to the pres- 
sure on the ureters. Marked caput succedaneum. 

Treatment. — If the true conjugate is between Z\ and 
3f in. (8 and 9 cm.) labor should be induced prematurely 
in the thirty-fifth or thirty-sixth week ; or the head may 
be pressed down firmly on the brim of the pelvis for one 
and one-half minutes, once a week from the time the 
child begins to be viable (for size and compressibility of 
fetal skull, see § 2) ; or forceps may be applied. If the 
conjugate measures over 3f in. (9 cm.), an expectant policy 
may be pursued, the woman being placed on the s;de 
toward which the occiput presents. Version is applicable 
only to exceptional cases. If the fetus is dead embryot- 
omy is to be performed. 

Table of Indications foe the Induction of Premature Labor. 

Conjn.eata vera 31: in. (8 cm.) in the 35th week. 

Conjiisata vera 3 to 3^ in. {Ih to 8 cm.) in the 31st to 34th week. 

Conjugata vera 3 in. (7i cm.) before the 30th week. 

This applies to flat pelves as well. If the true conjugate 
is 2J in. (6 cm.) the induction of abortion is usually 
necessary. 

Table of Indications for the Application of Forceps and for 

Embryotomy. 

Peine Contraction. Conjufiata Vera. 

First degree, 3^ to 4 in. (8.,5 to 10 cm.) ; 

Second degree, 2^ to 3| in. (7 to 8.5 cm.) ; 

Third degree, 2^ to 2| in. (5.5 to 7 cm.). 

With a conjugate of 2-| in. (7 cm.) the application of 



ANTEROPOSTERIORLY CONTRACTED PELVES. 215 

forceps is possible under favorable conditions ; 3^ (8 cm.) 
is the usual limit. 

If the conjugate is less than 2|- in. (6.5 cm.) in a gen- 
erally equally contracted pelvis, or less than 2^ in. (5.5 
cm.) in a flat pelvis, even a mutilated child cannot be 
extracted. 

Spontaneous delivery at term has occasionally been 
observed in flat pelves with a true conjugate of less than 
3j in. (8 cm.). 

These indications being based on the length of the true 
conjugate are, of course, influenced by the force of the 
labor-pains, the possibility of properly preparing the 
parturient tract, and all the other minor determining 
factors. 

Anteroposteriorly Contracted Pelves. 

(Figs. 118-122, 125, 127-132). 

No. 2. — Flat non-racliitic pelvis. 

Xo. 2a. — Simple flat non-rachitic (erroneously desig- 
nated Deventer's) pelvis (Fig. 118). 

Etiology. — Arrested development. The most frequent 
pathological form is probably due more to an inherited 
tendency than to overwork and the carrying of heavy 
weights in early childhood. 

Charade rhtics. — Shortening of the conjugata vera at 
the inlet, and, to a lesser degree, of the anteroposterior 
diameter of the true pelvis ; in other words, the sacrum 
as a whole is displaced forward without rotation around 
its transverse axis (as in the rachitic) and reduced in size 
in all its parts. As a result the posterior superior spines 
project far backward and the distance between them is 
diminished ; the opposite condition obtains in the equally 
contracted pelvis. 

Slight inclination of the sacrum. Often double prom- 
ontory (Fis:. 138). Relation between spines and the crest 
normal, hence not rachitic. Distance between the poste- 
rior superior spines d iminished, transverse diameter slightly, 
external and diagonal conjugates markedly diminished. 



216 DEFORMITIES OF THE PELVIS. 

In some cases the deformity can be detected with absolute 
certainty only by Skutsch's method (Figs. 44 and 56). 

Influence on Pregnancy. — Pendulous abdomen and ab- 
normal positions and presentations of the fetus are more 
frequent than in generally contracted pelves. 

Labor. — The width of the pelvis being normal, the 
head engages with the sagittal suture in the transverse 
diameter of the pelvis and, as it slowly effects an entrance, 
undergoes two different rotations, as follows : 

(a) The posterior parietal bone is pushed up toward the 
promontory, so that the sagittal suture is brought nearer 
to the promontory (Nagele's obliquity, see Fig. 130). 

(6) The small bitemporal diameter (3^ in. = 8 cm.) 
rotates into the true conjugate, that is to say, there occurs, 
in addition to Nagele's obliquity or presentation of the 
anterior parietal bone, a presentation of the greater fon- 
tanel, which can be readily palpated. In this transverse 
position the head descends to the pelvic outlet. In lumbo- 
sacral lordosis, especially in rachitic pelves with a high 
degree of scoliosis and a greatly contracted conjugate, the 
head enters the brim in extreme flexion (as in the ,2"en- 
erally contracted pelvis) in the extramedian position (Fig. 
140), that is, fixed in one-half of the pelvis. 

In breech presentations the prognosis is most favorable 
when the chin engages first ; in other words, the smallest, 
suboccipitobregmatic periphery (12f in. = 32 cm.) ; other- 
wise the chin is apt to catch on the horizontal ramus of 
the pubis. 

Diagnosis. — Conjugata vera, 3^ to 4 in. (8 to 10 cm.), 
usually more than 3| in. (9 cm.). 

In calculating the true conjugate from the diagonal 
conjugate in flat pelves it must be remembered that the 
inclination of the symphysis is much less, and hence the 
diagonal conjugate relatively greater. Instead of |- in. 
(1.5 cm.), from J to 1^ in. (1.8 to 3 cm.) — in rachitic pelves 
— must be subtracted from the diagonal conjugate to obtain 
the true conjugate. 

Treatment. — If the true conjugate is between 3 J and 



ANTEROPOSTERIORLY CONTRACTED PELVES. 217 

3f in. (8 and 8.5 cm.), induction of premature labor 
between the thirty-fourth and thirty-sixth weeks, or ver- 
sion sub partn is indicated. The forceps is applied only 
when the head is transversely placed deep in the excava- 
tion (hollow of sacrum), or after it has passed the superior 
strait and the force of the labor-pains is beginning to 
diminish. In primiparse it is better to wait, as the head is 
small and labor-pains are usually vigorous, later, forceps ; 
in multipara?, version. The unfavorable but rare presenta- 
tion of the posterior parietal bone should be corrected 
when the head first enters the inlet ; otherwise version, 
but not forceps. The woman should be placed on the side 
toward which the brow presents, so as to favor the 
entrance of the smaller, anterior portion of the head 
(sinciput) into the inlet. 

The danger of rupture of the uterus is greater than in 
generally contracted pelves. 

The treatment mentioned under Xo. 1, " generally con- 
tracted pelves,'' of forcing the head into the pelvic inlet 
during the latter part of pregnancy, is useful in this variety 
of deformed pelvis. 

Xo. 2b. — Generally and fiat contracted, non-rachitic 
j)elvis (generally unequally contracted, non-rachitic pelvis). 

Etiology. — Arrest of development. 

Characteristics. — Shortening of all the diameters, espe- 
cially of the anteroposterior at the inlet, due not to ante- 
rior displacement of the sacrum, but to the imperfect 
development of the portions of the innominate bone which 
surround the inlet. Probably not so very rare as is usually 
stated. The promontory is very high and displaced back- 
ward, hence from f to 1 in. (2 to 2.5 cm.) must be sub- 
tracted from the diagonal conjugate in calculating the 
conjugata vera. 

The infiuence on labor is the same as in the correspond- 
ing rachitic form. 

Xo. 3. — Flat rachitic pelvis. 

No. 3a. — Simple flat rachitic pelvis (Figs. 119, 121, 
125, 127-132). 



218 DEFORMITIES OF THE PELVIS. 

Etiology. — Rachitis. The proliferation of cartilage and 
bone-cells is normal, but there is defective deposition of 
lime salts, or the lime-salts already deposited are absorbed 
because the blood-vessels in the bone-forming structures 
are increased in number and overfilled with blood, and 
thus bring about a more rapid liquefaction of the cartilage 
and the already ossified tissues (cf. Fig. 124 with Fig. 
125). 

The effect is twofold : 1. Distortion of the skeleton by- 
pressure and traction, as explained in § 4. The effect is 
exaggerated on account of the softness of the bones. 2. 
Infantile arrest of development in the insufficiently nour- 
ished bones. Hereditary tendency may be present in 
some cases. 

CharaGteristics. — The distance between the anterior 
spines is equal to, or even greater than, the distance 
between the crests, because the ilia are flattened and 
pushed backward. This condition of the iliac bones is 
the result of flattening and of the absolute, or at least 
relative, increase in the separation of the two iliac bones. 
Owing to lordosis of the lumbar vertebrse the sacrum 
sinks forward into the pelvis, the effect of the excessive 
weight of the trunk in childhood w4ien the rachitic soften- 
ing process is most active. The posterior superior spines 
project backward and the distance between them is dimin- 
ished. There is backward displacement of those portions 
of the sacrum which articulate with the iliac bones (the 
first to the third vertebra) ; the remaining portions of 
the sacrum and coccyx are straighter than normal (cf. 
Fig. 13). Like most of the other bones the sacrum is 
diminished in size. Owing to the pull of the ligaments 
and muscles there is even a greater increase in the trans- 
verse diameter at the outlet. The pubic arch is usually 
more than 100 degrees. The symphysis is perpendicular 
and therefore tends to lengthen the diagonal conjugate; in 
common with the other walls of the true pelvis it is 
diminished in height. From a practical point of view it 
is important to note that all the synostoses, synchondroses, 



ANTEROPOSTERIORLY CONTRACTED PELVES. 219 

and synarthroses, etc., form sharp, projecting, bony points 
which mav easilv rupture the soft parts (cf. under ^' Acan- 
thopelys,'' § 20,' Xo. 12, and Fig. 148). 

Influence on Pregnancy. — There is an extraordinary 
tendency to uterine displacements : anteversion and ante- 
flexion with pendulous abdomen (see ^ 15c and Figs. 99, 
127-129), or retroversion and retroflexion, which may 
lead to serious incarceration under the promontory (see § 
\ba and Figs. 102, 103, 105). Eclampsia, on the other 
hand, is rare, probably because the ureters are protected 
from pressure by their position in the hollow spaces to 
either side of the convex body of the sacral vertebra. 
But for this very reason there is a greater predisposition 
to prolapse of an extremity or of the umbilical cord (five 
times more frequent). Owing to the length of time con- 
sumed in overcoming the difficulties at the inlet or to an 
abnormal presentation an excessive amount of amniotic 
fluid is produced, and rupture of the membranes usually 
occurs prematurely, that is, before engagement of the 
head in the superior strait; in 56 per cent, of the cases it 
occurs only after the os is fully dilated. The head engages 
in the same way as in the flat non-rachitic pelvis, which 
has been described (cf. preceding form, 2a, Figs. 130-132). 
The muscular effort is usually much greater, and the 
danger of rupture of the soft parts or of the pelvic joints, 
especially at the sharp projections described, correspond- 
ingly increased (see § 20, Xo. 12, and Fig. 148). Great 
liability to localized necrosis and fistula formation. Vertex 
presentations are less frequent by 10 per cent. ; the dura- 
tion of labor is increased by 50 per cent. Caput succe- 
daneum very pronounced ; the outline of the entire skull 
suffers a corresponding degree of disfigurement and injury; 
the posterior parietal bone, which is forced against the 
promontory, receives an indentation, or even a fracture, 
and subdural hematomata are formed (Figs. 130-132). 
Labor-pains are irregular, both on account of the purely 
mechanical resistance and indirectly on account of circula- 
tory disturbances. 



220 DEFORMITIES OF THE PELVIS. 

Diagnosis. — Conjugata vera is usually above 3J in. (8 
cm.) (cf. tables and remarks under No. 1, generally con- 
tracted pelves). General rachitic habit. Flat receding 
iliac bones. The distance between the anterior superior 
spines is equal to, or greater than, the distance between the 
crests ; the promontory is easily palpated. External and 
diagonal conjugates are shortened; from f to IJ in. (1.8 
to 3 cm.) must be subtracted in calculating the conjugata 
vera. The descent of the promontory may also be inferred 
from the prominence of the posterior superior spines and 
the diminution in the distance between them. 

Treatment. — The same as for flat non-rachitic pelves. 
It is to be remembered that owing to the perpendicular 
position of the symphysis the difference between diagonal 
and the true conjugate is greater (|^ in. = 2 cm.) than it 
is in non-rachitic pelves. The measurements of the out- 
let are to be taken into account, as has been explained 
under No. 5 ; in certain cases the perforator may be re- 
quired instead of the forceps. 

No. 36. — Generally contracted, flat rachitic pelvis 
(Fig. 120). 

Etiology. — Rachitis. The softer the bones and the 
earlier the disease makes its appearance, the deeper and 
more anterior is the position of the body of the first sacral 
vertebra, the greater tlie compression of the lateral walls 
of the pelvis in front by the femora, and the more imper- 
fect the development of all the bony parts. 

Characteristics. — Transitional form between the simple 
flat rachitic and the collapsed '^ pseudo-osteomalacic 
pelvis," inasmuch as it owes its shape to an earlier and 
more intense softening process than to that which produces 
the "simple flat rachitic pelvis," and has, therefore, suf- 
fered a lateral compression in addition to the flattening, 
the compression being greater in the transverse direc- 
tion than in the conjugate on account of the pressure of 
the femora. The result is a triangular shape (Fig. 120) 
of the inlet ; in other respects it bears all the marks of a 
"simple flat rachitic pelvis" in contradistinction to the 



ANTEROPOSTERIORLY CONTRACTED PELVES. 221 

rarer non-rachitic, generally equally, and flat contracted 
pelves. The outlet, however, is smaller, hence also the 
distorting effect of the muscles and ligaments Avhich is 
seen even in the flat pelvis is greater : the psoas and 
sacrospinal muscles act on the lumbar lordosis and on the 
upper portion of the sacral bone, which they tend to 
straighten; the iliosacral bones counteract the outward 
rotation of the iliac bones. 

Influence on Pregnancy. — The promontory projects far 
into the pelvic cavity, leaving a greater amount of ^Most" 
(dead) space on either side for the uterus and its contents, 
but the anterior half of the pelvis available for this purpose 
has the same special characteristics as the ^^ generally 
equally contracted pelvis," hence there is an extraordinary 
tendency to anteflexion with pendulous abdomen (Figs. 99 
and 129), abnormal positions and presentations of the 
fetus, and anomalies in the shape of the uterus (trans- 
versely elliptical, round, or obliquely distorted). 

Labor. — ^The head in this variety also engages with 
the sagittal suture in the transverse diameter of the inlet ; 
eventually the occiput descends as in the generally con- 
tracted pelvis, the posterior parietal bone usually present- 
ing. Presentation of the anterior parietal bone is very 
iinfavorx^ble. Rotation around the small oblique diameter 
occurs very late. 

In pelvic presentations the chin is the first to enter the 
inlet, the head, therefore, passes in this case also in the 
smallest or snboccipitobregmatic periphery (12J in. = 32 
cm.) ; any other mechanism is most unfavorable. Prolapse 
of an extremity or of the cord is readily explained by 
the " lost (dead) angles " on either side of the promontor}^ 
There is great liability to rupture, both of the soft parts 
and of the pelvic joints ; marked caput succedaneum ; 
injury to the parietal bone by the promontory (subcutane- 
ous and subdural hematomata. Figs. 130-132), the result 
of the extraordinary duration of labor and the triangular 
shape of the inlet so ill adapted to the fetal skull (Fig. 120). 

Diagnosis. — Conjugata vera often less than 3^ in. 



222 DEFORMITIES OF THE PELVIS. 

(8 cm.) (see tables and remarks under No. \, generally 
contracted pelves). 

The general signs of rachitis are more marked ; the 
stature is small. All the signs of a simple flat rachitic 
pelvis and, in addition, shortening of all the transverse 
diameters, even those of the outlet, are present. The 
iliopectineal line can be readily palpated. 

Treatment. — If the true conjugate measures 3^ to 3f in. 
(8 to 9 cm.) premature labor should be induced between 
the tliirty-second and thirty-sixth weeks; or, if the poste- 
rior parietal bone presents and the occiput has descended 
into the hollow of the sacrum, the forceps may be used. 
In presentation of the anterior parietal bone usually, and 
if the true conjugate is less than 3J in. (8 cm.), always, 
craniotomy or Cesarean section is called for. 

In primiparse with only a moderate degree of contrac- 
tion it is advisable to defer the induction of premature 
labor until the thirty-eighth or fortieth week (Ahlfeld). 

Collapsed Pelves. 

(Figs. 122, 126, 128.) 

No. 3c. — Collapsed racJiitic or pseudo-osteomalacie pelvis 
(Fig. 122). 

Etiology. — Rachitis. When the bones are very soft 
and the already formed layers of lime-salts undergo 
secondary liquefaction, the acetabula and promontory, 
being most exposed to pressure and traction, show the 
effect of compression most markedly. The symphysis is 
protruded in the form of a beak, while the iliac bones 
are bent backward. 

Characteristics. — The inlet resembles that of the osteo- 
malacic pelvis, being shaped like a heart in cards. 
Marked descent of the promontory ; inward compression 
of the acetabula and beak-like prominence of the symphy- 
sis. The small iliac bones are flat and displaced back- 
ward. The tuberosities of the ischium are approxi- 
mated. 

Influence on Pregnancy. — During pregnancy the posi- 



COLLAPSED PELVES. 223 

tion of the uterus is high, from failure of the presenting 
part to enter the superior strait, oblique positions of the 
fetus arise, etc. 

Labor. — Spontaneous and forceps delivery are equally 
impossible in most cases. 

Diagnosis. — Extraordinarily deep position of the prom- 
ontory ; the symphysis is beak-shaped ; the characteris- 
tic outline of the iliopectineal line is readily palpable. 
Manifestations of rachitis are present. The real conjugata 
vera is no criterion for the possibility of labor. 

Treatment. — Cesarean section is required in almost 
every instance. 

No. 4. — Osteomalacic collapsed pelvis (pelvis halis- 
teretica, Fig. 123). 

Etiology. — Osteomalacia. The lime-salts in the per- 
fectly developed bone of the adult undergo absorption 
and are not replaced by cartilage as in the child ; nothing 
remains but the fibrous tissue devoid of lime-salts (Fig. 
126). In contradistinction to rachitis there is here an 
inflammatory process, accompanied by decalcification and 
dilatation of the Haversian canals and medullary spaces; 
the calcified bone-substance containing bone-cells is re- 
placed by lamellar connective tissue, hence the flexibility 
of the osteomalacic pelvis (osteitis plus osteoporosis). 

Characteristics. — As the bones of the pelvis begin to 
soften, the transverse diameter is diminished, the altera- 
tions beginning in the anterior pelvic wall in response to 
the pressure of the femora. Later the characteristic 
alterations just described for the pseudo-osteomalacic 
rachitic pelvis make their appearance, and the most 
severe grades of deformity and compression result, so 
that even digital exploration per vaginam becomes im- 
possible on account of the approximation of the tuberosi- 
ties of the ischium. The pubic arch disappears or as- 
sumes an octagonal shape. The central portion of the 
sacrum is also markedly displaced upward and backward, 
but — in contradistinction to the rachitic pelvis (cf. Fig. 
141) — the tip of the coccyx projects forward so that the 



224 DEFORMITIES OF THE PELVIS. 

sacrococcygeal curve is greatly increased and the outlet 
markedly contracted in the anteroposterior diameter. 
The iliac bones present a deep furrow running from the 
iliosacral articulation obliquely upward and forward to 
the crest or to the anterior spines ("sulcus iliacus'^). 
The incomplete fractures which are frequently seen are 
due to softening of the medullary portion of the bone, 
while the shell remains intact. The so-called " rubber 
pelves/^ finally, are absolutely soft and yielding. 

Chai^acteristics. — The course of labor depends solely on 
the degree of softening. If the disease has been cured the 
pelvis is set in its pathological shape and spontaneous 
labor is impossible. For this reason a careful examina- 
tion should be made during pregnancy to determine 
whether there is retroflexion and incarceration of the 
uterus (see § 15a and Figs. 102, 103, 105). Acute signs 
of osteomalacia must be looked for, such as pains in the 
bones (beginning in the horizontal rami of the pubis), 
muscular cramps^ compressibility of the bones (beginning 
at the outlet), and especially the peculiar waddling 
gait. In many cases, given variously as from 17 to 
80 per cent., spontaneous labor is poss'ble if the flexi- 
bility of the bones is such as to permit distention of the 
pelvic canal ; if not, Cesarean section is usually the only 
possible procedure. Whether the ovaries should be re- 
moved or a complete Porro am])utation performed at 
the same time, with the view of curing the disease, is still 
an open question which need not be discussed in this 
place. In some cases the induction of premature labor 
might be considered. 

For the rest, the shape and size of the interior of the 
pelvis should be carefully investigated. 

The diagnosis of the osteomalacic pelvis based on the 
presence of a transverse fold in the skin above the pelvis, 
the beak-like shape and upward displacement of the sym- 
physis, the contraction at the pelvic outlet, and the 
diminution in the intertrochanteric distance (see § 3). 

Treatment. — During labor the distention of the " lower 



FUNNEL-SHAPED PELVES. 225 

uterine segment '' must be carefully watched, as rupture 
is very apt to occur. Excessive distention of the lower 
uterine segment is a contra-indication for version. If the 
pelvis is flexible the application of forceps may under 
favorable conditions be considered. Craniotomy is rarely 
called for ; Cesarean section is the usual procedure. 

Funnel=shaped Pelves (see ^ 20, No. 11). 
(Figs. 51, 134-136, 138.) 

No. 5. — Funnel-shaped pelvis, generally or anteroposte- 
riorly contracted at the outlet. 

Etiology. — The pelvic outlet may be contracted in gen- 
erally and in flat contracted pelves, in spondylolisthesis, 
osteomalacia, and in bilateral svnostosis (cf. Xos. 4, 66, 7, 
10). 

!N"o. 5a. — Infantile or undeveloped pelvis (Fig. 134). 

Etiology. — Arrest of development ; abnormally high 
position of tlie promontory witli flattening of the sacrum, 
perhaps with early, although not necessarily abnormal ossi- 
fication, whereby the character of the infantile pelvis is 
retained and the weight of the trunk is applied more pos- 
teriorly, so that transvere enlargement of the pelvis be- 
comes impossible, etc. ; in other words, an accentuation 
of the infantile properties. 

Characteristics. — Contraction chiefly and most fre- 
quently in the transverse diameter of the outlet (Fig. 43, 
§ 3); then in the conjugate of the outlet; frequently all 
the diameters of the pelvic outlet are diminished. Mod- 
erate diminution in the transverse diameter^ of the outlet 
is an obstacle to labor only when all the segments forming 
the outlet are contracted, or when there is anterior luxa- 
tion and fixation of the coccyx. 

The rest of the spinal column is norn\al ; even the form 
and position of the sacrum - and promontory are some- 

1 A very good instrument for the measurement of the transverse diam- 
eter of the outlet has been devised by Klien (Dresden). 

2 The sacrum is long and narrow and usually shows only a slight in- 
clination, but this is not due to an increase in the transverse and 
decrease in the longitudinal curvature, as Schauta found, since it also 

15 



226 DEFORMITIES OF THE PELVIS. 

times quite normal, the greatest contraction is found at 
the outlet, especially in the transverse diameter, the true 
pelvis itself being rather high. 

Influence on Pregnancy. — TJie pelvic inlet being normal, 
round, or oval, with the long axis in the anteroposterior 
plane and only a slight degree of contraction, the present- 
ing part regularly enters the true pelvis and there is no 
tendency to uterine displacements, etc. 

Labor. — As labor progresses the presenting part meets 
with serious resistance, for it cannot move in any direction. 
The normal rotation into the anteroposterior diameter 
takes place in the line connecting the spines of the ischium 
(§ 7) ; the shortening of this line, which represents the 
smallest diameter, and of the distance between the tuber- 
osities prevents this rotation. The head, for instance, is 
arrested with the sagittal suture in the oblique or in the 
transverse diameter, i. e., the largest diameter of the head 
coincides with the smallest diameter of the pelvis, while 
the occiput often slips past the spine of the ischium into 
the posterior portion of the excavation. But by the time 
the head has reached the spines of the ischium, after pass- 
ing through the pelvic inlet, the greater part of the trunk 
has escaped from the fundus, which is the only portion of 
the uterus capable of contraction, and the expulsive forces 
come to a standstill. While the danger of rupture from 
distention of the lower uterine segment is slight, pressure- 
necrosis in the vagina and vesicovaginal and urethrovagi- 
nal fistulas are very apt to result. 

Diagnosis. — The transverse diameter of the outlet, or, 
in other words, of the plane of pelvic contraction and the 

occurs in pelves with a high promontory and a flat sacruru. In such 
cases it is due to the greater height of tlie body of the first sacral verte- 
bra over the ala, thus converting the transverse diameter into two lines 
running downward. The pelvic inlet is usually round with a tendency 
to the ovoid shape, the result of the anomalies in the sacrum ; it is 
higher than normal and more concave from side to side, while the in- 
sertion of the innominate bones is situated more anteriorly. The in- 
clination of the pelvis is a little greater than normal, the symphysis 
somewhat more perpendicular — in short, the pelvis presents infantile 
characteristics. 



FUNNEL-SHAPED PELVES. 227 

conjugate of the outlet, are found to be diminished (Fig. 
42, § 3), while the measurements of the false pelvis are 
normal, especially those of the pelvic inlet. The tip of the 
coccyx is easily ])alpated. The limits which permit the 
delivery of a full-grown, vigorous child at term are as 
follows : Distance between the tuberosities of the ischium 
3^ in. (8 cm. ; normal : about 4 in. = 10 cm.) if the other 
measurements of the outlet are normal, or the distance 
between the tuberosities is 3|- to 3f in. (3.5 to 9 cm.), and 
the distance from the tuberosities to the tip of the coccyx 
only 2|- in. (7 cm. ; nornial : 3|- in. = 9.75 cm.), or the 
conjugate of the plane of contraction under 3f in. (9 
cm.; normal: 4J in. = 11.5 cm.). If the shape and 
position of the sacrum are normal and the pelvic outlet 
is funnel-shaped, we have to deal with a simple infantile 
arrest of development. 

Treatment. — In moderate grades of contraction inaction, 
and later, forceps. If. however, the distance between the 
tuberosities is 3^ in. (8 cm.), or the conjugate of the plane 
of pelvic contraction under 3f in. (9 cm.), craniotomy, or, 
possiblv, symphysiotomy or Cesarean section, is the only 
treatment. Particular care is necessary in the use of the 
forceps, on account of the great danger of extensive con- 
tusions or of separation of the pelvic joints. If the dis- 
tance betAveen the tuberosity and the tip of the sacrum is 
reduced to 2|- in. (7 cm.) the forceps may be employed 
onlv when the distance between the tuberosities measures 
at least 3f in. (8.5 cm.), always provided that we are deal- 
ing with a skull of normal strength belonging to a 
matured fetus. If the measurements fjill below this limit, 
and a living child is desired, sym])hysiotomy or Cesarean 
section must be done ; the former operation to be followed 
by the application of forceps down to 21 in. (5.5 cm.) as 
the limit for the distance between the tuberosities. A 
transverse presentation is always to be converted into a 
cephalic presentation ; version is not permissible. The 
induction of premature labor in the thirty-fourth week 
may be considered if the distance between the tuberosities 



228 DEFORMITIES OF THE PELVIS. 

is not less than 2|- in. (6.5 cm. — from 2J to 2|- in. = 8 
cm. to 6.5 cm.). 

No. 56. — Fetal, undeveloped decubital pelvis (Fig. 51). 

Etiologii. — Prolonged confinement in bed with absolute 
inability to move or sit up. 

Charadenstics. — The spinal column is almost as straight 
as in the fetus, so that the sacrum is practically the con- 
tinuation of the axis of the vertebral column ; the prom- 
ontory is high and projects very little. The inclination 
of the pelvis is considerable, although the physiological 
anteflexion does not take place ; on the other hand, the 
rotation described in § 4, No. 2, does not take place either, 
and thus the anterior pelvis is not elevated. 

There is no transverse expansion and the sacrum re- 
mains narroAV and straight, the iliac bones continue flat 
and small. The pelvic inlet is round or ovoid and the 
true pelvis distinctly funnel-shaped. The genitalia them- 
selves do not develop and there is no record of a woman 
with such a pelvis having given birth to a child. 

No. 5c. — Lumbosacrokyphotic funnel-shaped pelvis (Figs. 
135 and 136). 

Etiology. — Rachitis or caries in the lumbosacral or 
lumbodorsal region. 

Characteristics. — The kyphotic lumbar vertebrae draw 
the first sacral vertebra backward and upward, so that the 
promontory is flattened and displaced upward. In order 
to maintain the equilibrium the anterior portion of the 
pelvis has to be raised and the pelvic inclination is there- 
fore diminished. In this position the sacrum does not sup- 
port the weight of the trunk to the normal extent and is, 
therefore, unable to effect transverse expansion. The pos- 
terior superior spines become approximated, the innomi- 
nate bones are flattened because the iliosacral ligaments 
are relaxed on account of the failure of the sacruui to 
descend and draw them forward. On the other hand, the 
lower arms of the lever — the iliac and ischiatic bones- 
become approximated ; i. e., the transverse diameter of 
the outlet is shortened. In addition, the tip of the coccyx 



FUNXEL-SHAPED PELVES. 229 

is rotated forward and thus tends to increase the contrac- 
tion at the outlet. The diminished transverse concavity, 
which may even go on to convexity of the sacrum, and 
the ^vide separation of the iliac bones are the only signs 
of rachitis. 

Influence on Pregnancy. — There is a tendency to pen- 
dulous abdomen on account of the lordosis of the upper 
portion of the vertebral column, and consequent diminu- 
tion in the size of the abdominal cavity. 

Labor. — Longitudinal position of the fetus is the rule, 
the largest diameter of the presenting part usually adapt- 
ing itself to the oblique diameter of the pelvis. 

Course and treatment are the same as for infantile 
funnel-shaped pelves. 

Diagnosis. — The time at which the vertebral disease 
occurred is ascertained and the probable influence on the 
development of the pelvis determined. The iliac bones 
• are widely separated, the symphysis projects, the pelvic 
inclination is diminished. The pubic arch and the diam- 
eters of the outlet are contracted. In contradistinction 
to spondylolisthesis the lateral portions of the iliopectineal 
line is easily reached with the palpating finger, while the 
promontory is almost or quite beyond its reach. 

No. bd. — Pelvis obtecta, spondylolisthesis in the lumbar 
reg'on. 

Etiology. — The same as in the preceding, but the 
kyphosis is compensated by marked lordosis of the low- 
est lumbar vertebrae. 

^ Characteristics. — The kyphosis is compensated imme- 
diately above the pelvic inlet by the projection of the 
lowest lumbar vertebrae, thus forming a pelvis obtecta, 
resembling the spondylolisthetic pelvis. 

The influence on labor is the same as in the preceding 
pelvis. 

No. be. — Kyphoscoliotic funnel-sliaped pelvis. 

Etiology. — Eachitis. 

No. bf. — Pelvis icith contracted outlet due to luxation 
and anJcylosis of the coccyx. 



230 DEFORMITIES OF THE PELVIS. 

The characteristiG sign is the involvement of the sacrum 
in the kyphoscoliosis. On the side of the scoliosis the 
pelvic inclination is very slight (usually the left side); 
on the other, it is quite marked. This oblique distortion 
is combined with the funnel shape of the true kyphotic 
pelvis. At the outlet the distort on is reversed. (For 
further description see under scoliotic obliquely contracted 
pelvis, No. iki.) 

Obliquely Contracted Pelves. 

(Figs. 139-142.) 

No. 6. — Obliquely distorted or contracted pelvis. 

No. 6a. — Obliquely contracted pelvis due to scoliosis or 
lordoscoliosis (Figs. 139 and 140). 

Etiology. — Rachitis. The " non-rachitic " acquired form 
of kyphoscoliosis does not produce any alteration in the 
shape of the pelvis. The weight of the trunk presses 
more heavily on the side corresponding to the scoliosis, so 
that the ala of the sacrum on that side is pushed inward. 
The counter-pressure of the femur on the innominate bone 
produces an oblique distortion of the opposite lialf of the 
pelvis. If scoliosis is combined with kyphosis a torsion 
of the vertebrae is produced in a direction opposite to that 
of the scoliosis. The resulting abnormal pull on the ilio- 
.sacral ligaments draws the venter of the ilium in the same 
direction. This traction, combined with the counter- 
pressure of the femur, pushes the ilium and the entire 
half of the pelvis corresponding to the scoliosis upward, 
producing a vertical position of the pelvis with the ante- 
rior margin of the venter of the ilium nearer the median 
line. 

Characteristics. — The oblique distortion takes place 
either in the direction opposite to that of the undeveloped 
ala ; i. e., in the sagittal ])lane of the last lumbar vertebra, 
or in the direction corresponding to the diseased hip-joint. 
The lumbodorsal scoliosis is compensated by the oblique 
contraction of the pelvis, the compensation being effected 



OBLIQUELY CONTRACTED PELVES. 231 

either by scoliosis of the sacrum alone to the opposite 
side, or by rotation of the last lumbar vertebra. In 
general, the direction of the latter indicates the direction 
of the oblique contraction, and on this side the ala of the 
sacrum will be found imperfectly developed and the iliac 
bones perpendicular or even inclined inward ; the corre- 
sponding half of the pelvis is higher than the other half 
and the curve of the iliopectineal line is diminished : 
hence, 1, the true conjugate is shortened ; 2, the distance 
between the alae of the sacrum is diminished on the same 
side ; and, 3, the oblique diameter from the sacro-iliac 
articulation on the same side is lengthened. The tuberosity 
of the ischium on the side of the scoliosis usually projects 
outward, so that the transverse diameter of the pelvic 
outlet is increased (Fig. 139). For the rest, we have all 
the signs of the rachitic pelvis. 

The diagnosis is based on the general signs of rachitis 
and on the age at which the disease first made its appear- 
ance. The pelvis shows all the general characteristics of 
rachitis, and the oblique contraction is determined by 
palpation, by measuring the height of the crests in relation 
to the costal margin, and by determining the degree of 
torsion of the vertebral column. If the obliquity is very 
marked, it will show itself in a difference between the two 
external oblique diameters (§ 3) ; the more marked these 
differences are, in the following measurements of Xagele 
and others, the more certain is the diagnosis of even a 
mild grade of oblique contraction ; no one pair of oblique 
diameters is in itself sufficient to establish the diagnosis. 
The first four give the most reliable results both in the 
skeleton and in the living subject (author's own measure- 
ments) : 

(1) The external diagonal of the false pelvis = 9 in. (22.5 
cm.) on the average in viva. 

(2) The width of the iliac bone (posterior superior spine 
to anterior superior spine) — 6|- in. (16.8 cm.) on the aver- 
age in viva. 

(3) The distance between the anterior superior spine to 



232 DEFORMITIES OF THE PELVIS. 

the spinous process of the fifth lumbar vertebra = 7|- in. 
(18.6 cm.) on the average in viva. 

(4) The distance between the posterior superior spine 
and the symphysis = 7 J in. (18.5 cm.) on the average in 
viva. 

(5) The distance between the posterior superior spine 
and the tuberosity of the ischium of the other side = 8J in. 
(20.5 cm.) on the average in viva. 

(6) The distance between the anterior superior spine 
and the tuberosity of the ischium of the other side = 9^ 
in. (23.8 cm.) on the average in viva. 

(7) Height of the pelvis (from the highest point of the 
crest to the tuberosity of the ischium) — 8| in. (21.8 cm.) 
on the average in viva. 

Influence on Pregnancy. — During pregnancy the higher 
grades of contraction produce all the symptoms observed 
— a pronounced flat pelvis. 

Labor. — As indicated in Fig. 140 and described under 
the flat non-rachitic pelvis (2a), the head may meet with 
such marked resistance in the flattened half of the pelvis, 
which corresponds to the side of the scoliosis, that ^' extra- 
median engagement " takes place and the other half of the 
pelvis only is used. In its subsequent course the head 
meets with the same resistance as in the generally con- 
tracted pelvis: the suboccipitobregmatic periphery usually 
descends, with the lesser fontanel low down. Contractions 
of this severity are very unfavorable. 

Treatment. — At first expectant. From the thirtieth 
week of pregnancy on the head should be firmly pressed 
into the pelvic inlet for one and one-half minutes every 
week. 

In cases of marked shortening of the sacrocotyloid 
distance no attempt should be made to rotate the head so 
as to bring the sagittal suture into the larger oblique 
diameter. The latter is parallel with the flattened ilio- 
pectineal line and the corresponding half of the pelvis is 
often so contracted that it cannot accommodate the sinciput 
in the sacrocotyloid distance, whereas both transverse 



OBLIQUELY CONTRACTED PELVES. 233 

diameters of the head can pass if tliey lie parallel to the 
flattened iliopectineal line and the sagittal suture coincides 
with the shorter oblique diameter, the lesser fontanel sink- 
ing low down in the pelvis (presentation of the occiput). 

If labor cannot be terminated spontaneously, the only 
possible operations are craniotomy and Cesarean section. 

No. 66. — Obliquely contracted pelvis due to asymmetry 
of the sacrum (so-called secondary synostotic or Nagele's 
pelvis), Fig. 142. 

(The asymmetrically obliquely contracted assimilation- 
pelvis, see below, under ]S'o. 11.) 

Etiology. — Congenital absence of one sacral ala with 
displacement of the innominate bone and, usually, anky- 
losis of the sacro-iliac joint. 

There are no remains of inflammation. An inflamma- 
tion is not followed by such complete disappearance of the 
bone, and after ankylosis, which is given as the reason for 
the disappearance of the bone, there can be no displace- 
ment of the innominate bone. 

The iliopectineal line is flattened on the diseased side, 
the normal curve being preserved on the sound side. The 
flattening, displacement, and synostosis are due to the 
pressure of the femur on the sound side. 

Characteristics. — Complete or partial absence of one 
sacral ala vrith, usually, synostosis of the sacro-iliac 
articulation. The corresponding innominate bone is per- 
pendicular and rotated toward the median line, though as 
a whole it is displaced upward and backward : the curve 
of the corresponding iliopectineal line is flattened ; the 
symphysis is displaced to the other side, hence the sacro- 
cotyloid distance is diminished and the tuberosity of the 
ischium is displaced upward and inward or backward. 
The other half of the pelvis is well developed. The 
pelvic walls of the diseased side are approximated as far 
as the outlet. The shape is an oval with the long axis 
oblique, and retains its direction throughout. 

Diagnosis. — By exclusion of rachitic and other inflam- 
matory bone diseases. The difference in the height of 



234 DEFORMITIES OF THE PELVIS. 

the crests on the two sides is determined. The iliopec- 
tineal line most be palpated with great care and the dis- 
tances between the symphysis and the synostosis carefully 
measured to obtain the conjugate. If this distance is 
3| in. (8.5 cm.) or more, premature labor may be induced. 
The oblique diameter is to be measured as in the last- 
mentioned pelvis. 

Influence on Labor. — The available space during labor 
has the characteristics of a generally contracted pelvis 
with a triangular inlet, the conjugate of which corresponds 
to the line joining the symphysis and the iliosacral synos- 
tosis. The head is therefore in extreme flexion and 
presents with the occiput ; if the sacrocotyloid distance is 
very much diminished the same remarks apply as in the 
preceding pelvis. The contraction at the outlet presents 
serious difficulties ; even in vertex presentations the prog- 
nosis is unfavorable, in any other it is distinctly bad. 

Treatment. — The application of the forceps can only do 
harm and version is of no avail, because the head cannot 
pass. The choice, therefore, lies between the induction 
of premature labor, craniotomy, and Cesarean section. 
(For moderate grades of contraction, especially at the 
outlet, see Funnel-shaped pelvis, No. ba.) 

No. Qc. — Obliquely contracted 'pelvis due to primary in- 
flammatory synostosis of one sacro-iliac joint. 

Etiology. — Caries. The synostosis is primary. The 
shape of the pelvis depends on the date of the disease. 

Characteristics. — A variety of forms occur, ranging 
from the highest degree of asymmetry, as in Nagele's 
congenital obliquely contracted pelvis (due to secondary 
synostosis), to a perfectly symmetrical form, and includ- 
ing intermediate varieties due to disease in early child- 
hood. 

The diagnosis is based on the history of former in- 
flammatory process, the presence of scars, and the ab- 
sence of displacement of the diseased innominate bone. 

No. Qd. — Obliquely contracted pelvis due to impaired 
function of the hip-joint (Fig. 141). 



OBLIQUELY CONTRACTED PELVES. 235 

Etiology. — Coxalgia ; unilateral congenital luxation of 
the femur; early amputation, etc.; comminuted fracture 
of one innominate bone or of one sacral ala (Fritsch). 

All the bony parts of the diseased pelvic half from the 
tuberos'ty of the ischium to the crest undergo atrophy. 
The pelvis becomes perfectly perpendicular and assumes 
the characteristic funnel shape (like the diseased side of 
a synostotic pelvis). Owing to the pressure of the sound 
thigh the corresponding half of the pelvis is pushed over 
toward the diseased side, so that the sound half becomes 
flattened ; the acetabulum on the diseased side may be 
perforated. 

In the rarer form of simple coxalgia without the effects 
of the pressure of the thighs the diseased half under- 
goes contraction as in the synostotic pelvis, the sacral ala 
becoming atrophied, whereas in the former variety atrophy 
usually but not always occurs on the sound side, so that 
the sacrum is rotated on its longitudinal axis. 

In contradistinction to IS^agele's pelvis the oblique oval 
form observed at the inlet does not maintain the same 
direction as the outlet is approached, because the ischi- 
atic portion on the sound side is forced outward, or be- 
cause the forward and outward displacement of both 
tuberosities of the ischium tends to diminish the contrac- 
tion toward the outlet. 

Influence on Labor. — Luxation of one femur (usually 
backward and upward) produces various forms, depending 
on the age of the individual and use of the legs. 

(ci) Congenital Luxation. — When the child is lying 
down the diseased half of the pelvis atrophies ; the iliac 
bone is perpendicular on account of the pressure of the 
thigh against its outer surface ; the tuberosity of the is- 
chium is drawn up by the muscles attached to the tro- 
chanter. The child sits on the diseased tuberosity because 
it is the higher of the two, and this leads to oblique con- 
traction of the pelvis in favor of the sound side. In 
walking the child throws its weight chiefly on the sound 
thigh, hence the pressure is now applied to the sound 



236 DEFORMITIES OF THE PELVIS. 

side, and the diseased half of the pelvis becomes the 
greater. 

(6) Acquired Luxation. — If the luxation is acquired 
during childhood and the legs have never been used, the 
shape of the pelvis is the same as in the congenital form 
before the child has begun to walk, except that there is 
less atrophy. 

In adults who have not walked after the accident the 
diseased half of the pelvis becomes expanded by the 
traction of the iliofemoral ligament and the psoas muscle. 

In both children and adults who have walked after the 
accident the shape is the same as in congenital luxation 
jplus the effect of walking, but there is less atrophy and 
the displacement of the diseased side is less marked. 

For diagnosis and treatment, see previous variety. 

Transversely Contracted Pelves. 

(Fig. 144.) 

[No. 7. — Transversely contracted pelvis. 

No. 7a. — Transversely contracted pelvis due to absence 
of both sacral alee, Robert's pelvis (Fig. 144). 

(Other varieties of transversely contracted pelvis occur 
as tlie result of arrested development, such as the antero- 
posteriorly oval — funnel-shaped — pelvis and circular 
pelvis, which represent intermediate forms.) 

Etiology. — Arrested development. (In birds, bats, etc., 
there is fusion of the iliosacral joints ; the form is similar 
to the pelvis of most mammals.) The absence of centers 
of ossification is primary, the synostosis is secondary. 

Characteristics. — Fusion of both iliosacral articulations 
with consequent enormous diminution of the transverse 
diameter. Both halves of the pelvis are shaped like the 
diseased half of a Nagele's pelvis, the characteristic asym- 
metry of which is sometimes seen in intermediate forms. 
The iliac bones are displaced upward and backward. 

The diagnosis is based on the intertrochanteric distance, 
the beak-like shape of the symphysis, and the enormous 



ANOMALIES OF THE PELVIS. 237 

contraction of the entire cavity of the true pelvis with 
backward displacement of the sacrum. 

Treatment. — Induction of abortion or Cesarean section. 
The OS is very inaccessible on account of the contraction 
of the true pelvis. 

Xo. 76. — Transversely contracted pelves due to primary 
inflammation and secondary synostosis of both iliosacral 
articulations. 

Etiology. — Caries. (Until the fifth year of life the 
lateral growth of the sacral alse is cartilaginous ; the 
growth is not completed until the fourteenth year.) 

Characteristics. — Analogous to the form described 
under Obliquely contracted pelves, Xo. ^c, except that 
the deformity in this case is bilateral. History and evi- 
dences of an inflammatory process in childhood. Even 
the milder grades are funnel-shaped. 



Anomalies of the Pelvis due to Congenital or Early Acquired 

Defects. 

(Figs. 145-147.) 

Xo. 8. — Luxation of both femora (Fig. 145), club-foot, 
absence of the lower extremities, etc. 

The ^^ decubital'' pelvis (Fig. 51) is described under 
the head of Fetal undeveloped pelvis, Xo. 56. 

The ^' sitz-pelvis" is contracted in its anteroposterior, 
and expanded in its transverse diameter, like the pelvis 
in luxation of both femora. 

The club-foot pelvis is contracted transverselv (Fig. 
146). 

Etiology. — Congenital or due to traumatism in early 
infancy. 

Congenital. — (a) Development of the head of the femur 
in an abnormal situation high up on the iliac bone, with- 
out the formation of an acetabulum ; (6) the same, but 
with the formation of an acetabulum. 

Conjugate rarely under 3^ in. (9 cm.), usually between 
Z\ and 4 in. (9 and 10 cm.). 



238 DEFORMITIES OF THE PELVIS. 

Talipes varus on both sides. The leg is moved as if it 
were rigid ; posterior displacement of acetabulum and 
tuber ischii. Marked pelvic inclination. 

CharacteristiGs. — As the center of gravity is displaced 
backward the lumbosacral portion and the sacrum are 
forced downward between the innominate bones either in 
front or behind : the promontory and tip of the coccyx 
project, while the central portion of the sacrum recedes. 
The transverse diameter as well as the inclination of the 
entire pelvis is increased^ while the true conjugate is 
diminished ; the iliac bones are perpendicular. 

Diagnosis. — Waddling gait, pendulous abdomen due to 
the lumbar lordosis and shortening of the true conjugate ; 
the pelvis is very wide ; the trochanters come in relation 
with the outer surface of the iliac bones so that they are 
not touched by Nekton's line (anterior superior spine to 
tuberosity of the ischium) ; the thighs are adducted and 
rotated inward. The differential diagnosis from spondy- 
lolisthesis is based chiefly on accurate measurements and 
the relation to Nekton's line. 

Influence on Pregnancy. — Pendulous abdomen. 

Labor. — The indications for operative interference are 
the same as in the flat pelvis. At first inaction, as the 
great transverse expansion and shallowness of the pelvis 
often lead to precipitate delivery. Operations are diffi- 
cult to perform on account of the extreme adduction of 
the thighs. 

Double talipes. As a result of the backward displace- 
ment of the acetabulum and tuberosity (see Etiology) the 
pelvic inclination is markedly increased, the promontory 
is low and prominent, and the entire pelvis nuich con- 
tracted in its transverse diameter. When both legs are 
wanting (" Sitzbecken "), the shnpe of the pelvis is the 
same as in double luxation : lengthening of the transverse 
diameter with approximation of the crests ; marked flat- 
tening. 

No. 9. — Split pelvis, pelvis fissa (Fig. 147). 

Etiology. — Congenital failure of union between the two 



SPONDYLOLISTHETIC PELVES. 239 

halves of the pelvis, almost always associated with ex- 
stropiiy of the bladder. The weight of the trunk plus 
the pressure of the thighs produce marked rachitic charac- 
ters. 

Characteristics. — In the fetus the gap in the symphysis 
measures from 1 J to 2 J- in. (3 to 6 cm.) ; in the adult, 
from 3^ to 6 in. (8 to 15 cm.). Marked increase in the 
transverse diameter at every point; the sacrum falls for- 
ward ; the distance between the anterior superior spines is 
increased, that between the posterior superior spines is 
diminished. In rare cases synostosis of the iliosacral 
articulation is present, thus permitting function. The 
distance between the thighs is markedly increased. 

The influence on labor is the same as in the justomajor 
pelvis. After labor prolapse of the uterus occurs regu- 
larly, otherwise the deformity occasions no obstetrical 
difiiculties. 

Spondylolisthetic Pelves. 

No. 10. — Spondylolisthetic pelvis (Fig. 143). 

Four grades are distinguished : (1) The fifth lumbar 
vertebra projects over the base of the sacrum ; (2) It pro- 
jects over the pelvic inlet; (3) It slips into the pelvic 
inlet ; (4) It lies completely within the true pelvis. The 
latter variety may lead to fracture. 

Etiology. — External injury and inflammatory processes. 
The interarticular portion is elongated ; it represents the 
line of fusion of the anterior and posterior centers of 
ossification in the fetus. If fusion fails to take place 
fixation is eflected by ligamentous masses (sjwiuJyloh/sis 
inter articular is), Avhich predisposes to later spondylolis- 
thesis. 

Characteristics. — Contraction of the pelvic inlet due 
to the anterior dislocation of the body of the fifth lumbar 
vertebra. Lordosis of the lumbar portion is produced, 
so that the central vertebrse are on a level with the sym- 
physis, wliich is higher than normal, while the upper 
portion of the sacrum is displaced backward and the 



240 DEFORMITIES OF THE PELVIS, 

lower portion forward, as in the funnel-shaped pelvis. On 
these factors depends the degree of contraction. 

The lateral interarticular portions of the last lumbar ver- 
tebra become elongated (cf. Fig. 143) and thus give sup- 
port to the spondylolisthetic vertebral column. Synostosis 
takes place between the bodies of the vertebrae. 

The pelvic inclination is practically obliterated ; the 
transverse diameter of the false pelvis is increased, while 
the pelvic inlet is slightly, and the outlet markedly, con- 
tracted. The anteroposterior diameters are all diminished. 

Influence on Pregnancy and Labor. — Pendulous abdo- 
men. Tendency to transverse positions. If the pelvic incli- 
nation is slight, marked lordosis of the lumbar spine exerts 
an unfavorable influence on labor; the head in its descent is 
unable to adapt itself to the sudden increase in the 
angle of the pelvic cavity. The degree of contraction 
may be so slight that labor may be terminated spon- 
taneously, or Cesarean section may be required. 

Diagnosis. — There is a history of injury in childhood. 
Lumbar lordosis and prominence of the hips laterally ; the 
thorax reaches almost to the pelvis and transverse folds 
of skin are seen. The conjugatosymphyseal angle is 
diminished and the rima pudendi is placed too far for- 
ward. The presence of the spondylolisthetic angulation 
is most easily detected by palpation, beginning at the 
lumbar portion and going down, and the marked gib- 
bosity between the kyphotic sacrum and the lordosed 
lumbar spine affords an important diagnostic point to dis- 
tinguish this variety from the rachitic and from the 
lumbosacrokyphotic pelvis. 

Treatment. — A conjugata pseudovera of 2| in. (6 cm.) 
is an absolute indication for Cesarean section ; from 2| 
to 3 in. (6 to 7.5 cm.) for craniotomy or Cesarean section ; 
from 2|- to 3J- in. (7 to 8 cm.) for induction of premature 
labor between the thirty-second and thirty-sixth weeks ; 
from 3^ to 3f in. (8 to 9 cm.) for expectant treatment. 

Podalic version should never be employed (see Funnel- 
shaped pelves, No. 5a). 



ASSIMILA TION-PEL VES. 241 

AssiiiiiIation=pelves with so=calIed *♦ Intercalated " 

Vertebra. 

No. 11. — Assimilation-pelvis with intercalated vertebra 
(properly called transitional vertebra). 

No. 11a. — Asymmetrical assimilation-pelvis (Fig. 137). 

Etiology. — Hereditary arrest of development or imper- 
fect development. Either the twenty-fifth vertebra has 
not assnmed its sacral character on both sides or the 
twenty-fourth vertebra partially partakes of the sacral 

type. 

Characteristics. — On one side there is complete absence 
of the ala, on the other side the transverse process of 
the lumbar vertebra is preserved. Thus, the imperfectly 
developed vertebra is not properly supported and de- 
scends. Lumbar scoliosis results and, finally, oblique 
contraction of the pelvis toward the opposite side is 
superadded. When combined with rachitis these pecu- 
liarities are very marked. The oblique contraction does 
not take place when the articular surface of the lower 
vertebra projects upward and thus supports the imperfect 
upper half of the vertebra. 

No. 116. — Symmetrical assimilation-pelvis (Fig. 135). 

Etiology. — The same as in the last variety, except that 
either the twenty-fourth vertebra has developed with a 
sacral vertebra — upper assimilation ; or the thirtieth ver- 
tebra has done so — lower assimilation. 

Characteristics. — In upper assimilation, where the 
entire twenty-fourth vertebra forms part of the sacrum, 
the promontory is high ; the intervertebral disk between 
the first and second vertebrae persists, and the angle of 
the promontory is very little developed. As a result the 
curvature of the lumbar portion is diminished and the 
center of gravity is displaced forward ; compensation is 
effected by diminution in the pelvic angle and slight 
anterior inclination of the upper portion of the body. 
The transverse diameter is diminished and the pelvis 
assumes the funnel shape characteristic of the kyphotic 
pelvis. 

16 



242 DEFORMITIES OF THE PELVIS. 

There are cases of true supernumerary vertebrae in the 
form of arches without bodies, since the latter are derived 
from the arch (Gegenbauer, Rosenberg). 

Anomalies of the Pelvis due to Bone=tumors and Exostoses 
the Result of Fractures. 

(Figs. 148-150.) 

No. 12. — Acanthopelys (Fig. 148). 

Often seen in rachitic individuals. Ossification of the 
ecchondroses which normally form as the individual de- 
velops (Virchow). 

The spiny exostoses are seen at the symphysis, the 
iliopubic tubercle (acetabulum), the sacro-iliac synarthro- 
sis, and the promontory. 

They often lead to necroses and to rupture of the 
uterus. 

No. 13. — Tumors of the pelvie bones. 

No. 13a. — Encliondroma (Fig. 150). 

Heteroplastic, hence first formed from pre-existing 
cartilage (Virchow). They show a tendency to ossifi- 
cation. 

They usually grow from the posterior wall of the pelvis 
and fill almost the entire excavation, like fibromata. 

Cesarean section is usually required. 

No. 136. — Fibroma, rarely as large as the last-men- 
tioned tumor. 

No. 13c. — Sarcoma. The most frequent varieties are 
round-celled, spindle-celled, and soft medullary sarcomata. 

They are usually very large and grow from the pos- 
terior wall. 

No. 13(i. — Cysts. Combined with sarcoma or enclion- 
droma. 

No. 13e. — Carcinoma. Metastatic. Rarely of large 
size ; it leads to osteoporosis, hence the bones are soft. 

No. 13/. — HydrorrhacMs. Due to failure of union. 
Secondary unilateral scoliosis and asymmetry. The sac 
should not be disturbed. 

No. 14. — Fractures (Fig. 149) of the sacrum, ramus of 



LACERATIONS OF GENITALIA DURING LABOR. 243 

the ilium, of the acetabulum, with or without callus- 

exostoses, aiul with or without oblique contraction (in 

Fritsch's case contraction was due to fracture of the right 

ala). 

Generally Enlarged Pelves. 

No. 15a. — Generally enlarged (justomaj or) pelves. 

Abnormal development, in women either of gigantic 
stature or of ordinary height. 

The increase in the various diameters rarely exceeds |- 
in. (2 cm.). The enlargement is greatest in the antero- 
posterior direction. 

No. 156. — Funnel-shaped enlarged pelvis. 

Abnormal development. The outlet is normal, the inlet 
only being enlarged. 

No. 15c. — Enlarged pelvis due to flattening of the iliaG 
bones. 

Abnormal development. Instead of 130 to 140 degrees, 
as in the normal female pelvis (150 to 160 degrees in the 
male), the angle formed by the iliac bone with the lateral 
wall of the true pelvis is 1 05 degrees. 

Influence on Labor. — Premature engagement of the 
head in the superior strait and rapid, or even precipitate, 
delivery if the labor-pains and the contractions of the 
abdominal muscles are vigorous. The head fails to per- 
form the regular rotatory movements ; the occiput may 
descend into the hollow of the sacrum or the anterior 
fontanel may present. 



CHAPTER YII. 
PATHOLOGY OF LABOR. 

^20. LACERATIONS OF THE GENITALIA DURING LABOR. 

(«) Rupture of the Uterus. — Pupture during pregnancy, 
especially if attended with marked septic phenomena, 
always raises a suspicion of criminal abortion. A rap- 



244 PATHOLOGY OF LABOR. 

Fig. 151. Child from an Oblique Presentation, Position with the Body 
Doubled on Itself, " Conduplicato Corpore " (neglected transverse posi- 
tion). — Labor was impossible; the child died. Arm and shoulder pro- 
lapsed and were markedly edematous and excoriated (original water-color 
from a preparation in the Heidelberg Gynecological Clinic). 

tured rudimentary horn or tubal sac has often been mis- 
taken for the rupture of a normally formed uterus. 
Spontaneous ruptures occur after Cesarean section, the 
uterus giving way at the site of the scar (see § 14, under 
Traumatism ; § 15, 16 ; § 17). Injuries during labor are 
divided according to their etiology as follows : 

(a) Lacerations ; (b) erosions, either («) incomplete, or 
(j9) complete or perforating, with or without total escape 
of the ovum into the abdominal cavity. 

Lacerations are also divided according to their seat into: 
(1) rupture of the fundus ; (2) transverse rupture going on 
to total separation of the body of the uterus from the vagina; 
(3) simple lacerations of the cervix ; (4) lacerations of the 
cervix with solution of continuity in the vaginal vault, 
especially dangerous on account of infection. 

The normal uterus in labor consists of the contracting 
muscular layer of the body which gradually diminishes in 
thickness as the cervix is approached, and in some cases, 
especially when the labor-pains are abnormally severe, 
ends abruptly at the contraction-ring, and of the distended 
"^ lower uterine segment,^^ which includes the lower portion 
of the body of the uterus as far as its attachment to the 
peritoneum and the cervix (cf. § 6). 

Below the uterus is fixed by the unyielding connective 
tissue of the lower portion of the cervix and of the vagi- 
nal vault and by the retractores uteri muscles, as described 
in § 6. Additional fixation is usually effected by the 
OS becoming wedged in between the head and the pelvic 
wall. The resistance is supplied by the advancing body 
of the child as it passes through the inlet, the external os 
being fully dilated. The tears which are thus produced 
have been described in § G and illustrated in Figs. 16 and 
17 in the text and on Plate 34, all taken from original 



LACERATIOXS OF GENITALIA DURING LABOR. 245 

preparations. The excessive longitudinal distention be- 
comes complicated by the pressure of the head against the 
pelvic wall. Hence we may have rupture even in the 
absence of pelvic contraction in hydrocephalus (Figs. 133, 
133(7, 152, 153, and 157), or in oblique positions of the 
fetus (see Fig. 98 and in the author's Atlas of Labor and 
Operative Obstetrics), especially in spontaneous develop- 
ment and in partus conduplicato corpore {Ibid, and Fig. 
151). The contraction-ring recedes to the level of the 
navel, while the lower uterine segment becomes excessively 
distended. Thus the child's trunk is forced into the lower 
uterine segment and the latter begins to bulge. This is 
the time of greatest danger. The contracting fundus is 
held fast by the round ligaments, v>diich are stretched to 
their utmost. If the abdominal pressure is not sufficient 
to force the head into the true pelvis it becomes danger- 
ous because it acts throuo^h the bodv of the fetus on the 
lower portion of the uterine wall, which is already sub- 
jected to excessive pressure. The nerve-centers in this 
region are st'mulated by this excessive pressure (§ 5) and 
thus give rise to renewed labor-pains and abdominal 
pressure. The fetal axis-pressure described in § 5 indi- 
cates the probable seat of the rupture. This pressure 
is increased even more by the introduction of the hand 
(violent rupture, rupture due to external violence), hence 
longitudinal tears occur most frequently in the lateral 
portion of the uterus. 

The tear begins as a subperitoneal hematoma, the blood 
collecting between the separated muscle-fibers. There 
may be extensive separation of the peritoneum without 
complete or perforating laceration necessarily resulting ; 
in Figs. 152 and 153 the remains of the original hematoma 
are seen. 

Rupture of the anterior or posterior wall is less fre- 
quent, but, according to my collection of " one hundi'ed 
and one complete ruptures with complete escape of the 
child into the abdominal cavity," appears to occur most 
frequently as a result of violent traumatism. Rupture 



246 



PATHOLOGY OF LABOR. 



of the fundus (Fig. 18 in the text), which by itself is 
exceedingly rare, was also observed to follow traumatism, 
as in tlie above-mentioned case of Simpson's, in which 
there was said to be fatty degeneration of the muscular 
layer, although the specimen was not examined until the 
third day of the puerperium. After the escape of the 




Fig. 16. — Funnel-shaped complete rupture of the uterus (Ru.), extend- 
iiioj from the contractiou-ring {C.R.) to within an inch of the external os 
{A. Mm.). This line corresponds to the posterior peritoneal attachment 
and to the insertion of the retractores uteri. Unt., Ut., S., lower uterine 
segment ; PL, placental site. 



ovum the amniotic sac may be completely preserved, 
especially if the rupture is due to the giving way of an 
old Cesarean-section scar ; but more frequently the am- 
niotic fluid is discharged into tlie abdominal cavity, an 
accident which does not necessarily lead to infection. 



LACERATIONS OF GENITALIA DURING LABOR. 247 



The most dangerous are transverse ruptures and those 
which open the vaginal vault. 

From a diagnostic point of view, therefore, it is of 
the greatest importance to determine the moment when 
excessive distention of the lower uterine segment begins. 
The contraction-ring is high (that is, more than a hand^s 




Fig. 17. — This rupture is analogous to that seen on Plate 34, except that 
it includes the lip of the external os. Both forms of rupture are particu- 
larly dangerous because the infectious germs in the vagina are able to 
make their way into the peritoneal cavity. Letters as in Fig. 16 (original 
drawings from preparations in the Munich Gynecological Clinic). 

breadth above the symphysis, or even as high as the 
umbilicus). The head fails to engage in the true pelvis, 
the lower uterine segment causes the abdominal walls to 
bulge, simulating an overfilled bladder. The lower 
uterine segment as well as the round ligament are tense. 
The fundus is very small and hard and no fetal portions 



248 



PATHOLOGY OF LABOR. 



can be palpated. Labor-pains follow each other in rapid 

succession ; pulse and respiration are greatly accelerated. 

If the woman suddenly goes into collapse, labor-pains 

cease, and blood is discharged from the vagina, Ave know 




3/ 







<ly J: AMr?v:\ 



^ 



Fig. 18.— Eupture of the fundus with the fetus in situ; laceration at 

the external os. 

that rupture has taken place. The accident can be 
diagnosed from the outside ; it is not necessary to intro- 
duce the hand for the purpose of making an exploration. 



LACERATIONS OF GENITALIA DURING LABOR. 249 

as it only gives the woman pain and tends to increase the 
danger of sepsis. The various parts of the fetal body can 
be distinctly felt through the abdominal walls and in some 
cases can even be seen. The presenting part, head or 
shoulder, is found to have receded from the pelvic inlet. 
Treatment. — If rupture is imminent the w^oman should 
be delivered immediately ; unless Cesarean section is 
absolutely indicated it should not be attempted,^ on 
account of the delay of the necessary preparation if it is 
to be performed according to the rules of antisepsis. 
Hence, perforation, craniotomy, embryotomy, or decapi- 
tation should be performed. Version should never be 
attempted. On no account should the woman be allowed 
to exert abdominal pressure. An anesthetic should be 
given, and if the child is alive and the presentation 
favorable the woman should be put into Walcher's posi- 
tion after the labor-pains have subsided. If rupture has 
already taken place the child should be at once extracted 
per vias naturales. If the child has been completely dis- 
charged into the abdominal cavity the same procedure 
should be attempted. I think I have attained my object 
of pleading in favor of celiotomy by the collection of one 
hundred cases ^ of this kind, and 'l shall adhere to my 
view until the publication of a new series of at least a 
dozen cases of delivery per vias naturales convinces me 
that better results are obtained in that way ; they were 
certainly worse In pre-antiseptic times. In any case of 
this kind the decision always depends upon whether in- 
fection of the peritoneum has occurred or not. Celiotomy 
enables us to control the hemorrhage and to repair the 
rupture in the uterus properly, but it also adds the danger 
incident to the entrance of air, to the irritation of the 
intestines with hands and sponges, and to the caustic 
effect of antiseptic fluids. These things must be avoided 
as much as possible. If infection has already taken place 
it cannot be removed, and the least excoriation of the 
endothelium on the peritoneum permits its entrance into 

1 Miinch. med. Woch., 1889, and Inaugural Dissert., Munich, 1886. 



250 PATHOLOGY OF LABOR. 

Fig. 152. Complete Rupture of the Uterus ; one arm is protruded into 
the abdominal cavity; due to brow presentation of a hydrocephalic fetus 
in contracted pelvis (see Figs. 133, 133a). — Abnormal anterior rotation 
of the right coruu of the uterus ; the round ligament on the right side 
and the corresponding tube are visible (they were palpable before) ; the 
bluish color indicates the limits of the subperitoneal hematoma in the 
broad ligament and in the perimetrium. 

Fig. 153. The ruptured uterus of the same case (Fig. 152). (Both 
original water-colors from a case in the Heidelberg Obstetrical Poli- 
klinik). — At the fundus the fold in the perimetrium due to the con- 
tractions is readily recognized. The placenta and fetal membranes are 
in the fundus uteri. The umbilical cord passes through the iutact 
cervical canal into the vagina. The rupture is on the right side. The 
intraligamentary connective tissue was the first to give way, the result- 
ing hemorrhage (the cruor of which is visible) separating the serosa 
until it ruptured. The separation of the perimetrium can be plainly 
seen in the upper part of the picture. 

the peritoneal cavity. If this accident is avoided celiot- 
omy itself appears to have a favorable effect, as in 
tuberculous peritonitis. This has been proven experi- 
mentally and bacteriologically by Barbacci ^ and others ; 
clinically by Fritsch, v. Winckel, etc. 

Drainage of Douglas' pouch with iodoform gauze and 
drainage-tube, combined with compression of the abdomen, 
is applicable in most cases ; in others it will be better to 
drain by means of a strip of gauze inserted into the lower 
angle of the wound. 

If it is probable that infection has not taken place the 
question of suturing a smooth rupture might be con- 
sidered. 

In a case of fibrinous peritonitis the author once performed a 
successful Porro amputation twenty-seven hours after complete 
rupture with escape of the head into the region of the liver. The 
pedicle and Douglas' pouch were covered with iodoform gauze 
which was passed out through the cervix. 

Opening of the vaginal vault in combination with 
celiotomy always terminates fatally. There is one case 
reported by Leopold in which a cure was effected by 
means of a Porro amputation. The proportion of re- 

iSee abstract of mine in Centralbl. f. Gyn., about the end of 1893. 



Tab. 68. 




t 



"^- 








Fig. 152 



Tf 




Fio. 153 



AUh.AnsL t: RaichJhold. Miindien 



LACERATIONS OF GENITALIA DURING LABOR. 251 

coveries in celiotomy without this complication range 
from 26 to 100 per cent., according as the conditions 
are favorable or unfavorable ; that is to say, 26 per 
cent, when labor is protracted and other operative at- 
tempts are made or the vesico-uterine pouch is opened ; 
from 44 to 47 per cent, in cases of protracted labor 
with discharge of the amniotic fluid, but without at- 
tempts at operation. These results compare rather 
favorably with the results of Cesarean section, but 
they serve to show the danger of any other obstetrical 
operations per vias naturales. The general practitioner 
has no other recourse than to extract the fetus through 
the tear and then to tampon the cavity, or, after drawing 
the uterus down, to suture the lacerations with the aid of 
a grooved (Sims') speculum. This conservative procedure 
is the only one admissible in incomplete rupture without, 
or with only partial, escape of the child into the abdom- 
inal cavity, unless there is extensive laceration of the 
uterine wall and especially of the intraligamentary tissue, 
or infection has already taken place. Under such cir- 
cumstances vaginal hysterectomy or celiotomy with Porro 
amputation are the proper modes of procedure. 

(6) Erosions of the Uterine Wall. — As has been fully 
explained in §§ 17 and 19, and illustrated in Figs. 130- 
132, the fetal skull suffers characteristic indentations 
which may lead to hemorrhages, necroses, and incomplete 
fractures. The corresponding portion of the cervix also 
becomes perforated or local pressure-necrosis results. 
The seats of predilection are the promontory, the spiny 
prominences so frequently seen in the rachitic pelvis, the 
symphysis, and the iliopectineal line. The resulting 
losses of substance have a characteristic circular, funnel- 
shaped outline. They usually heal spontaneously, being 
at once incapsulated by the development of adhesive peri- 
tonitis. They do not give rise to any special symptoms. 

If the lesion occurs at the anterior wall a urinary 
fistula is apt to form. This occurs in the great majority 
of cases as a result of necrosis. The plug of necrotic 



252 PATHOLOGY OF LABOR. 

tissue separates in a few days, so that incontinence is not, 
as a rule, discovered until the third or fourth day of the 
puerperium. (For the treatment, see the author^s Atlas 
of Gynecology.) 

(c) Lacerations of the Cervix. — Lacerations at the os 
possess a certain significance, as they lead to characteristic 
ulcerations (Fig. 18 in the text) and sometimes to acute 
parametritis. 

Deeper tears of the cervix are usually produced by 
obstetrical instruments and, if they extend to the vaginal 
vault or into the subperitoneal connective tissue, may 
become very serious, as they come within the distribution 
of the uterine arteries (see § ], Fig. 3). The diagnosis 
between hemorrhage due to atony of the muscle and trau- 
matic hemorrhage is therefore of the highest importance. 
Only when the uterus feels hard to the touch is it per- 
missible to make a digital examination (always under 
strict aseptic precautions) for the purpose of examining 
the mucous membrane of the vagina, of the portio vagi- 
nalis, and of the cervix for the presence of lacerations. 

Treatment. — The tear should be sewed up either with- 
out the use of a speculum under the guidance of two 
fingers (in the dark, after Veit), the needle being held in 
a needle-holder and the uterus pressed down by an assist- 
ant, or with a speculum and Muzeux's tenacula. 

The etiology and the prognosis vary according to the 
site of the tear. For practical purposes we distinguish : 

(1) Lacerations of the vaginal vault ; 

(2) Lacerations in the central portion of the vagina ; 

(3) Lacerations in the fossa navicularis, with or with- 
out injury to the perineum. 

Lacerations of the vaginal vault are found almost ex- 
clusively in the posterior fornix, and are due either to 
external violence or to direct pressure of the head on the 
brittle and inelastic tissues of the vaginal vault, which 
has been drawn upward by the violence of the labor- 
pains before the head had entered the superior strait. In 
a normal pelvis the failure of the head to engage in the 



LACERATIONS OF GENITALIA DURING LABOR. 253 

superior strait is due to some abnormality in the labor- 
pains, /. ('., partial tetanus or unequal contractions of the 
uterus, to the improper direction of the contractions, as 
in pendulous abdomen, or when the women is delivered 
in a standing posture with the body bent forward. 

The tears produced in this way are very extensive and 
terminate fatally, either by undermining the vascular 
base of the broad ligament and giving rise to profuse 
hemorrhage, or, if the peritoneal cavity is opened, by 
peritonitis. More rarely death results from the decom- 
position of shreds of tissue in the cavities on either side 
of the uterus. The child and the fetal membranes are 
usually forced wholly or partially into the laceration. 
The symptoms in many cases are not at all alarming, but 
the prognosis must be considered unfavorable. 

Treatment. — Immediate extraction of the child per 
vias ncdurales on account of the danger of internal hem- 
orrhage ; repair of the laceration, especially of the serous 
membranes, or, if that is impossible, tamponade and 
drainage. If the operator is certain that the peritoneum 
is intact, irrigation may be practised later on, if the tissues 
decompose and the wound suppurates, or Stschetkin's 
plan of making an extraperitoneal lumbar incision with 
counter-drainage may be adopted. It is often difficult to 
determine whether or not the peritoneum is intact, as it is 
very much attenuated and loops of intestines can easily 
be felt through it. If the hemorrhage is uncontrollable, 
or the wound is very badly lacerated, vaginal extirpation, 
or, if necessary for the ligation of vessels, celiotomy must 
be resorted to. 

Tears in the central portion of the vagina are usually 
due to external violence, such as premature elevation of 
the forceps, and are usually longitudinal ; they rarely 
lead to the formation of a rectovaginal fistula. Much 
more frequently a vesicovaginal fistula results, which, as 
a rule, is not discovered until several days later, after the 
separation of the necrotic tissue, when incontinence of 
urine makes its appearance. 



254 PATHOLOGY OF LABOR. 

These tears are also to be carefully sewed np. Tears 
in the vagina and perineum are usually situated to one 
side of the posterior column of the vagina. They may 
occur during the passage over the perineum either of 
the head or of the shoulder. Occasionally the laceration 
is confined to the muous membrane of the fossa navic- 
ularis, so that the perineum and frenulum appear intact 
on tlie outside although extensively undermined in- 
ternally. 

According to the degree of functional disturbance to 
which they give rise perineal lacerations are divided into 
three grades : 

(!) Lacerations of the frenulum; 

(2) Lacerations extending to the sphincter ani ; 

(8) Lacerations into the rectum. 

These lacerations are to be at once repaired in every 
case (for the technique, see Atlas of Labor and Operative 
Obstetrics). If the sutures are introduced before the 
placenta is expelled, its subsequent extraction may prevent 
primary union. This mode of healing can be expected 
to take place in general only wlien the laceration is re- 
paired within the first six hours; occasionally it may be 
possible to obtain secondary union, as, for instance, when 
the laceration has not been repaired in the first place and 
the woman is obliged to go back to work soon after de- 
livery. 

Healing may occur even in spite of a marlced rise of tempera- 
ture. The author once saw a case in which the temperature 
rose to 103. G° F. (39.7° C.) on the first evening, a small abscess 
having formed, which ruptured toward the edge of the newly 
formed frenulum without interrupting the healing of the vaginal 
and perineal granulations. 

g3i. DYSTOCIA DUE TO ANOMALIES IN THE POSITION 
AND FORM OF THE GENITAL ORGANS, INCLUDING 
TUMORS. 

(a) Dystocia due to Malformations of the Genital Organs. 
— In rudimentary organs (uterus unicornis) or in the 
anomalies due to persistence of the bilateral fetal charac- 



DYSTOCIA. 255 

ter of the organ, such as uterus bicornis, uterus septus, 
vagina sej3ta, the sources of danger during labor consist 
in the great tendency to lacerations and in anomalies of 
the labor-pains, due to the weakness of the muscular 
tissue and their oblique direction with reference to the 
pelvic inlet. In the hrst place the malformation affects 
the position of the fetus. In uterus septus the position 
is longitudinal with a preponderance of vertex presenta- 
tions. In uterus bicornis with a common uterine cavity 
there is a greater liability to pelvic presentations ; in 
uterus introrsum arcuatus (Fig. 98) the lateral expansion 
of the uterine body often gives rise to transverse posi- 
tions of the fetus, the tendency being often increased by 
the shortening of the anteroposterior diameter, which 
frequently accompanies this anomaly. The relative 
width of the uterine cavity also predisposes to placenta 
prsevia. The disturbances which take place during preg- 
nancy have been discussed in § 15. 

Labor. — The deviation in the axis of the gravid horn 
of the uterus from the very beginning determines the 
expulsion of the fetus in an oblique direction, so that the 
opposite wall of the pelvis (Fig. 97) offers an increased 
resistance, and this, when assisted by the unequal distribu- 
tion of the muscular tissue and frequent displacement of 
the non-gravid horn of the uterus, may lead to lacera- 
tions of the lower uterine segment or to an extraordinary 
prolongation of labor (missed labor). A similar effect 
may be produced by the presence of a rigid septum in the 
vagina. Severe hemorrhage may result if the placenta is 
inserted in the septum of the uterus which is capable of 
contracting. 

A further obstacle to labor may be presented by the 
displacement of the non-gravid horn into the pouch of 
Douglas, which not rarely occurs. The uterus becomes 
wedged in under the promontory and obstructs the true 
pelvis. 

If pregnancy in a rudimentary cornu or in one which 
is completely shut off from the uterine cavity (see Fig. 



256 PATHOLOGY OF LABOR. 

Ill) goes on to term, Cesarean section with removal of 
the cornu is required. 

(b) Dystocia due to Acute Flexion and Sacculation of 
the Uterus. — Under this head are included anteflexion, 
lateroflexion, and sacculation of the uterus. 

Labor. — In anteflexion the force of the labor-pains or 
the power of the abdominal muscle may be defective. 
A more dangerous complication consists in the head being 
forced against the promontory ; that is to say, in the 
sagittal suture being brought nearer to that structure (see 
Figs. 130, 131, and in the author's Atlas of Labor and 
Operative Obstetrics, Fig. 15, Nagele's obliquity); or in 
the head being forced down on the symphysis, thus 
causing angulation of the vertebral column {Atlas of 
Labor and Operative Obstetrics, Fig. 16, and severer 
grades), i. e., approximation of the sagittal suture to the 
symphysis (presentation of the posterior parietal bone). 
For further details see under Contracted Pelves, especially 
§§19, 20, Nos. 2 and 3. 

Treatment. — The anterior displacement of the fundus 
must be corrected by laying the woman on her back and 
maintaining a backward fixation of the uterus by means 
of towels and binders. (For operative procedures see the 
sections just referred to.) 

For similar reasons lateroflexion of the uterus, which 
is a frequent accompaniment of pendulous abdomen, 
especially if the woman lies on the wrong side or tosses 
about from side to side, may force the head against the 
lateral wall of the pelvis and thus lead to face or trans- 
verse presentations. The treatment consists in main- 
taining the head in a median position at the superior 
strait, or possibly in converting it into a footling pres- 
entation by means of pillows placed under the woman's 
body, by placing her on the appropriate side, and by 
means of external or internal manipulations (version ; 
manipulations for correcting the position of the fetus, see 
Atlas of Labor and Operative Obstetrics). 

Partial angulation and sacculation of the uterine wall 



DYSTOCIA. 257 

is observed toward the end of pregnancy, or during labor, 
whenever any part of the uterine wall becomes abnormally 
fixed. Thus, in already existing retroflexio uteri ; in 
arrest of the head under the promontory ; in perimetritic 
or parametritic distortions; when the uterus is fixed either 
too high or too far to one side and the anterior wall is 
unable to develop during pregnancy (vagino- and ventro- 
fixation) ; when myomata and cysts are present; when the 
gravid horn of a uterus bicornus is wedged in under the 
promontory ; and, finally, when the direction of the uterine 
contraction is abnormal in pendulous abdomen ; possibly, 
also, in retroposition or retroversion of an anteflexed 
(generally infantile) uterus in primiparee (Diihrssen). 

Sacculations may occur in the anterior or in the lateral 
walls, but are most frequent in the posterior wall — partial 
retroflexion of the uterus. Labor may be seriously pro- 
tracted or brought to a standstill if the head is forced into 
the sacculation. The external os fails to dilate and is 
usually displaced from the pelvic axis, so that the head 
pushes the sacculated portion of the wall farther and 
farther into the vagina ; or the head deviates at the pelvic 
inlet and impinges on the lateral wall of the pelvis, so 
that we have brow, face, or transverse presentations. The 
danger consists in laceration of the uterine segment or 
sepsis derived from old perimetritic foci. 

Treatment— T\\Q first thing to do is to determine 
whether the bladder is full and, if so, to empty it at once 
(see § 15, 2a). Next, the presenting portion (head) is to 
be brou2:ht in line with the internal os or with the pelvic 
inlet, while the external os and the cervical canal are 
returned to the pelvic axis. If possible the primary 
obstacle must be removed. 

When there is partial retroflexion of the uterus (Fig. 
103) and the head is movable in the pelvic inlet, podalic 
version and extraction offer the best prospects, if putting 
the woman in the proper position on the side correspond- 
ing to the deviating presenting part and forcibly pressing 
the head into the i)elvic inlet have not proved successful. 
17 



258 PATHOLOGY OF LABOR, 

If the head has entered the true pelvis and is movable, the 
anterior displacement of the os should be corrected with 
the finger, or a colpeurynter should be introduced into the 
cervical canal. If the cervical canal fails to distend, 
the vaginal vault should be opened as far as the ex- 
ternal OS, the incision extended into the lower uterine 
segment, and the child extracted through the aperture 
thus made. In the case of cysts, myomata, and uterus 
bicornis the force of the labor-pains is occasionally suffi- 
cient to draw the sacculated portion from the hollow of 
the sacrum up to the abdominal cavity, even in cases that 
have obstinately resisted manual reposition ; the latter 
should always be attempted before the abdomen is opened 
for the purpose of performing supravaginal amputation 
or total extirpation of the uterus. 

If rupture threatens, the patient should be anesthetized 
and a Champetier-Ribes colpeurynter inserted, or the 
above-mentioned incision may be performed. In trans- 
verse presentations that have resisted all attempts at 
correction embryotomy or Cesarean section is indicated. 
Every effort should be made to preserve the integrity of 
the amniotic sac, as its preservation materially improves 
the chance of dilating the cervical canal. 

(c) Atresise, Stenoses, and other Obstacles to Labor in the 
Soft Parts of the Parturient Canal. — Impregnation may 
take place when there is the smallest possible opening in 
the hymen, which may later even become entirely closed, 
or when the hymen is quite intact (hymen septus sive 
bifenestratus, see Atlas of Gynecology, Fig. 2 in the text). 
The head impinges on this obstacle, which must, therefore, 
be incised. A similar obstacle to labor is opposed by 
remains of septa in a double genital canal (vagina septa, 
collura septum, uterus subseptus). 

Even after impregnation has taken place atresise and 
rigidity of the vulva, vagina, and cervix may be acquired 
through ulcerations or severe inflammations of the vagina; 
they may be present before impregnation takes place in 
elderly priraiparse after operations on the portio vaginalis 



DYSTOCIA. 259 

(wedge-shaped excision) or plastic operations on the peri- 
neum. 

A case of this kind was in the Munich Gynecological Clinic in 
1892 and 1893. Nitric acid had been injected into the vagina to 
bring on an abortion. A few days before labor the vagina was 
opened and craniotomy was performed, when a cicatricial stenosis 
resulted. 

In all such cases there is danger of deep lacerations 
extending into neighboring organs, or of the external os 
being completely separated and prolapsing in front of 
the vulva. Hence an early incision is required, followed 
by the application of forceps or craniotomy or, if the 
parturient canal is obstructed by too great a mass of 
adhesions, Cesarean section may even be required. The 
so-called " conglutinatio orificii extern! ^' of primiparse 
consists simply in a stenosis of the rigid external os, which 
can scarcely be palpated. The treatment consists in dilating 
it with the finger and making shallow incisions. 

Large cystoceles with inversion of the vagina often lead 
to a tumor-like stenosis of the birth-canal ; they are par- 
ticularly dangerous when they are due to a vesical calculus. 
In such a case lithotomy must be at once performed. In 
simple cystocele the bladder should be immediately evac- 
uated ; the concavity of the catheter must be directed 
downward to correspond with the posterior deflection of 
the urethra. 

A similar obstacle is presented by a subcutaneous hema- 
toma of the vagina or vulva, which occurs in one-third 
of all the cases during labor on account of the great 
vulnerability of the venous plexuses and the increased 
intra-abdominal pressure. In twin labor it may seriously 
threaten the life of the second twin. As soon as there is 
danger of rupture or of labor coming to a standstill, the 
hematoma should be incised, the child rapidly extracted, 
and the hemorrhage controlled by ligating the bleeding 
vessels or by tamponade. 

In very rare instances labor may be obstructed by true 
vaginal tumors, fibromata, myomata, and cysts, which act 



260 PATHOLOGY OF LABOR, 

much in the same way as the myoma of the cervix seen 
in Fig. 107, which was spontaneously expelled. They 
require the same treatment. Cysts are to be punctured. 

(r/) Labor Obstructed by Uterine Fibromata. — The diag- 
nosis, the effect on labor, and the treatment have already 
been discussed, at least in part, in § 16a. It remains to 
determine what is the proper line of action when labor is 
already in progress and a complication of this kind exists. 

If the head is unable to make its way past the tumor 
into the true pelvis there is danger of rupture, usually of 
the fundus uteri. Submucous myomata of the cervix 
may be enucleated and ^' delivered " (Fig- 107). Large 
intramural myomata, on the other hand, form an absolute 
hindrance to labor and are, therefore, the most dangerous. 
Tumors situated high up, within reach of the uterine con- 
tractions, are often drawn up out of the true pelvis with 
astonishing ease when compared with the difficulty of 
manual reposition. 

Owing to the irregular outline of the pelvic inlet — not 
to mention the transverse presentations to which this con- 
dition often gives rise — there is great danger of prolapse, 
either of the umbilical cord or of one of the extremities. 
In addition there is great danger of injury to tlie cranial 
bones. A frequent result of a partial obstruction is 
placenta prsevia, as is tubal pregnancy. 

In addition to the mechanical obstruction to which they 
give rise tumors may exert injurious effects on account 
of changes in the tissue of the tumor itself or of the 
uterus. The fibrous elements undergo rapid ])roliferation 
and either become markedly edematous or undergo myxoid 
or colloid degeneration ; the contractile elements do not 
participate in the process. In this way they increase the 
danger of infection, of rupture, and of hemorrhage, and 
diminish the fn^ce of the labor-pains (missed labor, espe- 
cially in intramural myoma). The tumors are very liable 
to become crushed and then to slough. 

Tlie dangers to labor, therefore, consist in excessive 
duration with secondary diminution in the force of the 



DYSTOCIA. 261 

labor-pains ; rupture of the uterus ; obstruction of the 
birth-canal : anomalies in position and especially in the 
attitude of the child ; anomalies in the insertion of the 
])lacenta ; and prolapse of an extremity or of the umbil- 
ical cord. 

During the puerperal period the interference with 
uterine contraction predisposes to hemorrhage or retention 
of the placenta. 

Treatment. — This depends on the behavior of the my- 
oma. If neither the force of the labor-pains nor manip- 
ulation suffices to push it out of the way and it can- 
not be extirpated, or if from its size and position it con- 
stitutes an absolute hindrance to labor, the child must be 
delivered by Cesarean section at term or when it has 
reached viability. In most cases it is best to perform a 
supravaginal Porro amputation with retroperitoneal dis- 
posal of the pedicle, or total extirp'ation of the uterus Avith 
the placenta, so as to avoid the danger of sepsis and the 
effects of thrombosis and embolism. 

Another source of danger after delivery jjer vias 
naturales is found in the tendency of the myoma to 
slough, so that, even after a natural delivery, it may be 
wise to operate. 

On account of the elasticity of myomata and the 
changes in shape produced in them by the action of the 
labor-pains, the degree of pelvic contraction which they 
produce is not the same as that due to deformity of the 
pelvis ; if the tumor occupies about one-third of the pelvis 
and cannot be pushed out of the way, craniotomy is indi- 
cated in vertex presentations and extraction in pelvic 
presentations; if the tumor fills one-half of the pelvis 
Cesarean section is called for. 

(e) Labor Obstructed by Ovarian Tumors. — The most 
dangerous are the small solid ovarian tumors which 
remain fixed in the pouch of Douglas and prevent the 
head from entering the pelvis. The pressure on the tumor 
leads either to necrosis or to rupture, thus forming a 
favorable site for septic infection ; or rupture of the uterus 



262 PATHOLOGY OF LABOR. 

or of the vagina takes place. In some cases the tumor is 
squeezed flat and finally pressed up over the pelvic inlet, 
the pedicle in such cases being usually torn or twisted. 

treatment. — If attempts at reposition are unsuccess- 
ful, tapping is to be considered. If this procedure does 
not suffice, vaginal ovariotomy or even Cesarean section, 
followed by removal of the tumor, may have to be per- 
formed. 

(/) Labor Obstructed by Carcinoma. — The rigidity of 
the tissues and the possibility of delivery j9er vias naturales 
will depend on the amount of cervical tissue involved in 
the carcinomatous infiltration. If it is found that the 
presenting part fails to descend, and the vaginal portion 
does not dilate under the action of vigorous labor-pains, 
it may be inferred that the obstacle is insurmountable, 
and one of the following procedures is indicated : Deep 
crucial incisions in the portio vaginalis ; incision of the 
lower uterine segment through the anterior vault of the 
vagina after the bladder has been dissected away ; or, 
finally, Cesarean section, followed in every case by total 
extirpation of the uterus if the process has not yet ex- 
tended to neighboring organs, the body of the uterus 
being removed through the abdominal section and the 
cervix through the vagina. 

I 22. DYSTOCIA DUE TO ANOMALIES IN THE OVUM OR 

FETUS. 

Dystocia due to abnormal position, attitude, and pres- 
entation of the fetus has been discussed in the Atlas of 
Labor and Operative Obstetrics. 

(1) Twin and Multiple Pregnancies. — G. Veit found in 
the analysis of 13,000,000 births one case of twins to 88 
single births, one case of triplets to 7910 single births, 
and one case of quadruplets to 37,126 single births. 
About a dozen cases of quintuplets have been reported in 
modern times in various countries. 

Multiple pregnancy is due either to the fecundation of 
several ova discharged at the same menstruation or to the 



DYSTOCIA. 263 

fecundation of a single ovum containing several germs 
(see Fig. 5). In the latter variety (twins, etc., from one 
ovum) the fetal membranes are common, except that each 
fetus has its special amnion and the children are of the 
same sex ; in the former variety each fetus has its own 
chorion or decidua reflexa and the children may be of the 
same or of different sexes. 

In multiple pregnancies from a single ovum anas- 
tomosis of the placental vessels takes place and this leads 
to the so-called third circulation. If the latter is not 
symmetrical there results, according to Schatz, a diifer- 
ence in the development of the various fetuses. If one 
portion of the placental system is insufficient the cor- 
responding fetus dies and is known as fetus papyraceus, 
because it becomes miuumified and pressed flat by its 
fellow (Fig. 100). 

The diagnosis of twin pregnancy is determined by 

(1) The palpation of more parts of ■ the same kind than 
can be accounted for by one child (two amniotic sacs, two 
heads, and more than four extremities) ; 

(2) By the palpation of parts in such a situation that 
they cannot possibly belong to the same child ; 

(3) By hearing fetal heart-sounds distinctly in two 
widely separated areas and possibly with varying 
rhythms ; 

(4) By the possibility of varying the position of one 
child by means of pressure on the presenting part with- 
out aifecting that of the other. 

Occasionally a longitudinal groove can be made out on 
the abdomen. 

Labor. — As a rule, both twins are delivered in ver- 
tex presentations, but pelvic or abnormal presentations 
are much more frequent in multiple than in single 
births ; in more than two-thirds of all the cases labor 
takes place prematurely. It is protracted for the first 
child and accelerated for the remaining ones. The 
mortality is greater in multiple than in single births, 
especially for boys, because, according to Veit, they are 



264 PATHOLOGY OF LABOR. 

larger and possess less vitality. The placenta is usually 
delivered after the last child is born ; often the uterus 
fails to contract, in which case postpartam hemorrhages 
must be guarded against by the administration of ergot. 
The interval between the delivery of the two children 
may amount to several hours. If the placenta of the 
second child appears before the latter is born it must, of 
course, be extracted with all possible vspeed. 

The placental extremity of the umbilical cord of the 
jfirst child must always be ligated in order to prevent the 
second child from bleeding to death. 

(2) Malformations. — These rarely form an obstacle to 
labor. The most frequent form is internal hydrocephalus, 
consisting in dropsy of the lateral ventricles. In milder 
grades there is very little alteration in ±he fontanels and 
sutures, and it is, therefore, difficult to make the diag- 
nosis during labor. In severer grades with an effusion 
up to 1 pint (500 gm.) the cerebral substance becomes 
much attenuated, the convolutions are completely flat- 
tened, and the entire skull converted into a flaccid bag of 
skin, as the result of the excessive gaping of the sutures 
and fontanels. 

The condition is often associated with spina bifida and with 
malformations of the spine and spinal cord, of the diaphragm, of 
the abdominal parietes (umbilical hernia), with total absence 
of one kidney, talipes varus, congenital rachitis (micromelia), 
and with other forms of dropsy, such as ascites and polyhy- 
dramnion. Several hydrocephalous infants may be born by the 
same mother. 

The deformity often gives rise to a pelvic presentation 
because there is less room for the head in the lower 
uterine segment than in the fundus, into which it is forced 
by the uterine contractions. 

The diagnosis is difficult to make during labor. It 
is based on the wide separation of the fontanels and 
sutures, on the small triangular shape of the face in com- 
parison with the large globular skull, and on the diffi- 
culties encountered by the presenting or aftercoming head 



DYSTOCIA. 265 

in passing throngh the normal pelvic inlet ; these signs 
can be detected only with the entire hand in the uterus. 

The most difficult stage of labor is the entrance of the 
head into the pelvic inlet (Fig. 157). Under the action 
of the labor-pains the skull balloons out like a bladder 
and, being in the horizontal position, presents the largest 
periphery and the largest diameter. The deeper the an- 
terior parietal bone is forced into the pelvic canal the 
more favorable is the prospect that at least one segment 
will effect an entrance into the superior strait ; for in- 
stance, one-half the skull, or a brow, or anterior fontanel 
presentation. Tiiis tends to distribute the tension so that 
it acts partially above and partially below the superior 
strait. In this way labor may be terminated sponta- 
neously in one-fourth of all cases, although the prominent 
bony portions of the advancing segment are very apt to 
produce lacerations in the swollen portio vaginalis. In 
some cases perforation of the skull is called for on ac- 
count of the danger of rupture following the excessive dis- 
tention of the lower uterine segment. 

The size of the head may be abnormal as the -result of 
fissures in the skull and hernial protrusions (meningocele 
frontalis, superior, posterior, epignathus). Their inter- 
ference with labor is, however, less than in the case of 
marked hydrocephalus, because the hernial sacs are com- 
pressible and the skulls are usually small. A more 
serious obstacle is found in normal skulls of unusual size 
and hardness with correspondingly broad shoulders, 
especially in the children of elderly primipar?e. Forceps, 
version, and extraction of the aftercoming head, crani- 
otomy, decapitation, and cleidotomy should be tried in 
succession. Hemicephalic and anencephalic monsters de- 
scend in the so-called '' face presentation '^ (Fig. 154). 

The trunk may be enlarged from the presence of hernial sacs, 
spina bifida, and omphaloceles (hernia of the umbilical cord, 
ectopia viscerum). tumors (coccygeal teratomata), and dropsical 
swellings of the body (ascites, distended bladder, and hydrone- 
phrosis due to atresia of the urethra. Fig. 158). The diagnosis 



266 PATHOLOGY OF LABOR. 

Fig. 154. Presentation of an Anencephalus in so-called Face Pres- 
entation. 

Fig. 155. Presentation of Dicephalus DibracMus. 

Fig.. 156. Presentation of Thoracopagus (copied from Kiistner). 

Fig. 157. Hydrocephalus Presenting with Head in Partial Flexion ; 
excessive distention of the lower uterine segment with high position of 
the contraction-ring, C. R. (modified from Band!). 

Fig. 158. Distention of Bladder and Ureters with secondarj^ hydro- 
nephrosis, due to atresia of the urethra combined with ascites ; a coil of 
the umbilical cord has prolapsed (modified from v. Hecker). 



cannot be made with certainty. The condition may call for ver- 
sion, craniotomy, or incision with the longSiebold scissors. 

Among other complications may be mentioned double monsters. 
Figs, 155 and 156 illustrate the presentation of a diceplialus di- 
brachius and of a thoracopagus. The diagnosis can be made only 
after labor has begun by actual palpation of the monstrosity. 
Besides being very rare, these deformities are attended with little 
dangers to labor, as they practically always lead to abortion or 
premature labor. 

(3) Dystocia due to Anomalies in the Umbilical Cord and 
Fetal Membranes. — The life of the fetus may be endan- 
gered by compression of the umbilical cord when it forms 
loops and coils, which may even be converted into true 
knots by the fetus slipping through them (this may occur 
as late as the fourth month), by prolapse of the cord 
(Fig. 1 58), or bv torsion of the cord during pregnancy 
(Figs. 88 and. 100). 

The causes of prolapse of the umbilical cord are the 
same as those which produce prolapse of the extremities, 
namely, failure on the part of the large presenting part 
to fill the true pelvis. Compression can usually be de- 
tected by hearing the funic souffle (see §§ 6 and 7). A 
cord may be felt pulsating synchronously with the fetal 
heart. An attempt at reposition should immediately be 
made (after the method indicated in Fig. ^b, Atlas of 
Gynecology), or, better, version should be performed and, 
if the OS is completely dilated, immediately followed by 
extrnction ; if the os is not sufficiently dilated, combined 
version after Fehling should be employed, one extremity 
being left in the vagina with a fillet attached. 



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DYSTOCIA. 267 

As a rule, looping of the umbilical corJ leads to no 
disturbance until toward the end of labor, when the rela- 
tive shortening of the cord may form a more or less 
serious obstacle. Tlie diagnosis is difficult; the condi- 
tion may be suspected if the rotation of the head on the 
floor of the perineum is unduly delayed, the labor-pains 
increase in force, the fundus of the uterus becomes pain- 
ful, the recurrence of the fetal heart-tones in the intervals 
between labors is delayed, if the child ap})ears restless or, 
possibly, if the funic souffle is heard. Sometimes it is 
possible to feel a coil around the neck of the fetus 
throutrh the rectum. 

There is danger of the child becoming asphyxiated on 
account of hemorrhage, not only in placenta previa but 
also in velamentous insertion of the placenta. Fig. 14 
in the text shows at once how easily a vessel may be torn 
under these circumstances, hence the child should be de- 
livered with all possible speed, the amniotic sac being 
preserved intact as long as possible. The diagnosis is 
made by feeling the pulsating vessels in the external os. 
In puncturing the sac care should be taken to choose a 
non-vascular area. 

Retention of the placenta is sometimes due to adhesion 
of the placenta following endometritis, but more fre- 
quently to excessive size of the placenta or angulation of 
the uterine wall. In the former case the placenta must 
be detached with the hand under strict antiseptic precau- 
tions (see Atlas of Labor and Operative Obstetrics, Fig. 
42) ; but, as a rule, it is better to allow the mother to 
rest if there is no hemorrhage and to give ergot or mor- 
phine to quiet agitation. 

Premature separation of a normally implanted placenta 
occurs as a result of delayed rupture of the amniotic sac, 
traumatism, nephritis, eclampsia, infectious diseases, and 
of all the conditions which produce abortion. 

Symptoms. — Hemorrhage : internal when the blood ac- 
cumulates behind the placenta, external w^ien it makes 



268 PATHOLOGY OF LABOR. 

its way into the cervix past the loosened edge of the 
ovum. The condition is extremely dangerous. 

Treatment. — If the cervical canal is at least partially 
dilated immediate delivery should be effected either by 
forced labor {accouchement force), colpeurynter, or by 
Cesarean section ; if the uterus is atonic and the hemor- 
rhage cannot be controlled by hot injections, tamponade 
or the exhibition of ergot may be resorted to. 

§ 23. ANOMALIES IN THE LABOR=PAINS.— INTERDE= 
PENDENCE BETWEEN LABOR AND DISEASES OF 
OTHER THAN THE SEXUAL ORGANS. 

For the purely functional anomalies of labor-pains it 
is often impossible to demonstrate any local anatomical 
cause, and they must, therefore, be classified among the 
disturbances of innervation and metabolism, except in 
those cases in which a distinct constitutional or other 
organic disease can be demonstrated. 

GENERAL REMARKS ON DIAGNOSIS AND INDICATIONS 
FOR OPERATION IN DYSTOCIA. 

So far the discussion has been limited to the purely 
anatomical disturbances of pregnancy and labor, which, 
for diagnostic purposes, may be grouped schematically, 
according to causes, as follows : 

I. Abnormal resistance on the 'part of the mother. 

(1) Contracted pelves. 

(2) Stenosis, malformations, arrest of development or tumors 
of the soft parts. 

IL Abnormal resistance on the part of the fetus. 

(1) Unfavorable presentation, position, and attitude of the fetus. 

(2) Malformations of the fetus (hydrocephalus, tumors, tera- 
tomata). 

(3) Anomalies in the shape, contents, and position of the fetal 
membanes, and of the umbilical cord. 

III. Abnormally diminished resistance on the part of the bony 
and of the soft tissues of the birth-canal on the one hand, and of 
the child on the other hand, when the expulsive forces are normal 
or increased — producing transverse position of the head or precipi- 
tate delivery. 



AyOMALIES IS THE LABOR-PAINS. 269 

We now have to discuss another group, which includes 
simple functional disturbances of labor due either to 
anomalies in the abdominal ])re5sure and in the force of 
the labor-pains, or to constitutional diseases or other 
defects of the entire organism. Accordingly, ^ve have : 

IV. Functional disturbances of labor by 

(1) Anomalies of the labor-pains. 

(2) Other diseases of the mother. 

Operative interference is indicated only when the 
sequels of these anomalies distinctly threaten the life of 
either mother or child. These sequels and symptoms 
indicating operative interference we have found to be the 
following : 

A. On the part of the mother : 

I. Symptoms in the genital tract. 

(1) Excessive distention of the lower uterine segment ; upward 
displacement of the contraction-ring from a hand's breadth above 
the symphysis to the level of the umbilicus or higher; presence 
of pain during the intervals between the uterine contractions; 
small and weak pulse. 

(2) Rupture of the uterus (see § 20(7) with complete escape of 
the child into the abdominal cavity : symptoms of shock, recession 
of the presenting part, and hemorrhages from the genitalia. 

(3) Impending rupture of an ectopic gestation-sac (§§ 156, 17) 
or of a cyst (§ 16t/, or of a hematoma or thrombus in the vulva, 
I 21c, especially during the birth of a twin), or of an excessively 
dilated bladder, as in the case of an incarcerated retroflexed uterus 
(^216). 

(4) Impending perforation from erosion, localized pressure- 
necroses (I 206 I, lacerations of the vagina and perineum (| 2Qd in 
conditions of rigidity, stenosis, and funnel-shaped pelves, indicated 
by pallor of the frenulum). 

(5) Marked pain in the pelvic joints, a sign of impending lacer- 
ation of the joint capsules (contracted pelves, | 18). 

(6) Acute inversion of the uterus f§ 23, Xo. 1). 

(7) Hemorrhages in placenta praevia, premature separation of 
the placenta, retained placenta, atony of the uterus after labor, 
and with the above-mentioned injuries. 

II. General symptoms. 

(1) Infectious intoxications with fever or comatose or hectic 
conditions: (a) Sepsis with a temperature of 100.4° F. (38° C), 
pulse 100 and over, from local injuries of the genital tract or the 
decomposition of a fetus. (6) Eclampsia (see 1 13). (c) Tuber- 



270 PATHOLOGY OF LABOR 

ciilosis {I 14) ; the prognosis in labor is often serious on account 
of the loss of blood and the muscular strain, hence artificial 
termination of labor and anesthesia are indicated in the second 
stage. On the other hand, pregnancy itself usually runs a favor- 
able course. 

(2) Other organic diseases unfavorably influenced by labor, for 
instance, cardiac lesions (^ 14), which, according to Fritsch, are 
apt to bring on cardiac paralysis and pulmonary edema on 
account of the increase in the blood-pressure due to the labor- 
pains. Extreme debility and anemia. 

B. Symptoms on the part of the fetus. 

(1) Persistent retardation of the fetal heart-sounds down to 
100 or less, or persistent acceleration to 160 or over, with decrease 
in the force of the impulse. Funic souffle. 

(2) Passage of meconium. 

(3) Prolapse of the umbilical cord [I 22). 

(4) Hemorrhages from fetal placental vessels in velamentous 
insertions or in placenta prsevia (^ 22). 

I. Anomalies in the Labor=pains. 

{A) Increase in the Force of the Labor-pains. — Tetanus 
uteri (Wehensturm) occurs when the resistance is insuper- 
able, as in transverse presentations after discharge of the 
amniotic fluid, and particularly after protracted, ill-advised 
attempts at delivery, or after the exhibition of ergot during 
labor. These tonic contractions, while they in no way 
assist the act of parturition, are very apt to produce rup- 
ture of the lower uterine segment and death of the fetus. 

Treatment. — The labor is to be at once terminated in 
transverse presentations by means of embryotomy, the 
spasm of the uterus being first allayed by complete anes- 
thesia or by the injection of \ gr. (0 015 gm.) of morphine 
with y^Q^ gr. (0.0005 gm.) of atropine. Very often, how- 
ever, it is impossible to relax the uterus by giving an 
anesthetic if the contractions have already led to excessive 
dilatation of the lower uterine segment, besides, the dan- 
ger of infection is increased by the administration of a 
narcotic when the temperature is elevated and the woman 
is much debilitated ; in such cases, therefore, embryotomy 
is the proper procedure. 

Spastic strictures result from the same causes that pro- 



ANOMALIES IN THE LABOR-PAINS. 271 

duce tonic spasmodic contractions, and, of course, occur 
only in situations supplied with sphincter-like muscles, as 
at the uterine orifices of the tubes and at the external os 
(see Figs. 64 and 65). They occur rarely during lai:)or, 
as, for instance, in Kaltenbach's case, which is of medico- 
legal interest in that the stricture was situated in the 
region of the internal os and caused a constriction on the 
neck similar to that produced by a coil of the umbilical 
cord. Usually they occur during the postpartum' period, 
and may in some cases produce retention of the placenta. 

Treatment. — The condition calls for the administration 
of an anesthetic. 

Analogous to this last variety of spasmodic contractions 
we have the partial convulsive labor-pains which occur 
not infrequently and affect various asymmetrical portions 
of the uterine muscle. Their effect is to exert unequal 
pressure on the fetus or ovum, so that labor fails to pro- 
gress in spite of the apparent force of the contractions. 
The spasm is especially apt to occur in nervous and chlo- 
rotic women. 

Treatment. — The treatment is the same as for atony 
of the uterus, to which the condition is closely allied ; i. e., 
narcotics or possibly a single profound anesthetization. 

Abnormally vigorous labor-pains with lessened resist- 
ance in the birth-canal and fetus lead to ])recipitate 
delivery. The excessive force of the labor-pains is due 
to the presence of a hypertrophic substratum in the mus- 
cularis of the fundus, a condition which is not rarely 
hereditary. According to v. Winckel, an additional pre- 
disposing cause is found in multiple births and abnormal 
shortening of the umbilical cord. 

Treatment. — The woman is placed on her side and 
forbidden to bear down. The perineum should be pro- 
tected from the very beginning. If the condition changes 
to partial convulsive labor-pains anesthesia should be 
induced or a mustard-plaster applied. 

{B) Diminution in the Force of the Labor-pains.— This 
may be : 



272 PATHOLOGY OF LABOR. 

(a) Primarily either as the result of a general weakness 
due to anemia, starvation, or disease in a debilitated 
woman ; or as a result of defective development of the 
uterine muscle, be it physiological, on account of age 
(very young or very old primiparae), or dependent upon 
defective involution, especially after premature labors, or 
upon malformations of the uterus (uterus bicornis, unicor- 
nis, see §§ 15 and 21), or upon tumors in the uterine wall. 

(6) Secondary, resulting from abnormal distention (poly- 
hydramnion, multiple pregnancy, etc.), loss of blood 
(placenta prsevia), inflammatory disease (injuries and peri- 
metritic adhesions of the uterus, hysteropexy), or, finally, 
from displacement of the uterus. Among indirect causes 
may be mentioned insufficient abdominal pressure during 
the second stage of labor and congestion and inflammation 
of the pelvic organs. 

Diagnosis. — AH these etiological factors must be care- 
fully taken into consideration, and the force and dura- 
tion of the pains and of the intervals accurately noted 
by the condition of the fundus, the progress of the 
presenting part, and the dilatation of the entire cervical 
canal. The bladder and rectum must be carefully ex- 
amined and emptied if necessary. Finally, the general 
condition of the patient as to temperature and pulse must 
be determined, and after the discharge of the amniotic 
fluid the fetal heart-sounds should be counted. 

Atony of the uterine muscle leads to dangerous post- 
partum hemorrhages. 

Treatment. — This consists in stimulating the labor- 
pains bv means of hot baths, bv hot vaginal douches at 
from 93° to 100° F. (34° to 38° C— a pailful of steril- 
ized 0.6 per cent, salt solution or 0.25 per cent, lysol 
solution being injected every one or two hours), or by hot 
poultices, reaching from the fundus to the symphysis ; in 
the administration of diaphoretics and stimulants, the 
patient being first thoroughly quieted and allowed to sleep, 
and the bladder and rectum emptied. If all these measures 
fail, and if the os fails to dilate and the head is already 



ANOMALIES IN THE LABOR-PAINS. 273 

deeply engaged, a colpeiirynter should be introduced. 
This is indicated especially in overdistention of the uterus 
due to multiple pregnancy or polyhydramnion, in which 
case the amniotic sac should also be punctured early; it is 
not so appropriate, liowever, in painful affections. 

If labor does not terminate spontaneously, all the vari- 
ous operations for extraction may be considered : Manual 
expression of the fetus, after Kristeller, Fehling's and 
Ritgen's manipulations to hasten the delivery of the head 
(see Atlas of Labor and Operative Obstetrics), the applica- 
tion of forceps if the child's life is in danger or the 
mother becomes completely exhausted, and in the third 
stage of labor expression of the placenta after the uterus 
has become firmly contracted, either spontaneously or after 
half an hour's rubbino; and kneadino^ of the fundus and 
of the posterior wall, or, if the placenta is not delivered 
and hemorrhage occurs instead, extraction of the placenta. 
Ergot, ergotin, or cornutin may he given even in the 
expulsive stage if there is no abnormal resistance, pro- 
viding immediate artificial termination of labor is not 
intended. 

Such abnormal resistance is often due to secondary 
diminution in the force of the labor-pains, which will 
now be considered. 

(C) Seoondary Diminution in the Force of Lahor-pains, 
— If labor is too long delayed, the child dies after the 
discharge of the amniotic fluid and there is constant 
danger of infection from the invasion of micro-organisms, 
hence artificial delivery is indicated, massage of the fundus 
being kept up. Ergot is to be administered at the moment 
of delivery. 

If the atonic bleeding continues in spite of these 
measures — as may occur in hemophilia, arteriosclerosis, 
cardiac lesions, chronic nephritis, insufficient development 
of the muscle at the placental site — a hand should be 
introduced into the vaginal vault, the uterus bent over 
forward and kneaded between the two hands. In desper- 
ate cases the portio vaginalis should be drawn down to the 

18 



274 PATHOLOGY OF LABOR. 

vulva with Miizeux's tenacula and covered with sterile 
gauze. Tliis procedure, by distorting and obstructing the 
uterine vessels, will stop the blood-supply and thus arrest 
the hemorrhage, while the increased amount of carbon 
dioxide in the blood brings on contraction of the uterine 
muscle. 

A very serious but fortunately rare consequence of in- 
sufficient contraction of the lower portion of the uterus is 

Inversion of the Uterus. — It occurs chiefly as a result 
of improper treatment during the third stage of labor, 
such as undue traction on the umbilical cord before the 
placenta is separated and manual pressure on the uncon- 
tracted uterus. It may be partial, invaginating the fundus 
in the shape of a funnel, or complete, in which case the 
spherical body of the uterus is forced through the internal 
OS ; the condition calls for immediate^ re-inversion or the 
introduction of a colpeurynter after the placenta has sepa- 
rated (see Atlas of Gynecology). 

2. Interdependence Between Labor and Diseases of Other 

Organs. 

The most important disturbances and dangerous com- 
plications occur in the presence of cardiac insufficiency 
and tuberculosis. In cardiac insufficiency without com- 
pensation and with degeneration of the heart-muscle (see 
§ 14) death may occur suddenly during labor as a result 
of pulmonary edema and profuse dropsical effusions. In 
other cases the heart is arrested by cerebral or cardiac 
anemia secondary to venous stasis in the intestinal blood- 
vessels. During the third stage there is great danger of 
hemorrhage on account of the atony of the uterus. In 
the subsequent course of the puerperium there is an in- 
creased liability to infection on the part of the tissues on 
account of the disturbances to circulation and nutrition. 
A moderate postpartum hemorrhage relieves the patient and 
is not necessarily dangerous. If dyspnea occurs during 
labor (see the scheme in this section under Anomalies of 
Labor-pains) the woman is placed in a sitting posture and 



ANOMALIES TX THE LABOR-PAINS. 275 

hypodermai:ic injections of camphor and ether are ad- 
ministered, or, if necessary, the amniotic sac is prema- 
turely punctured. 

If dangerous symptoms develop, the child should be 
extracted as early as possible, but not too rapidly. 
Anesthetization may be useful in some cases. Dilatation 
of the OS is effected by means of the colpeurynter. Un- 
less the postpartum hemorrhage produces alarming symp- 
toms ergotin is contra-indicated ; on the other hand, the 
application of a sand-bag to the abdomen is very useful. 
During the first four days of the puerperium ether may 
be given, after that digitalis or strophanthus. 

The prognosis of labor and the puerperium in lung 
diseases (see § 14), be they acute, as croupous pneumonia 
or even influenza, or chronic, as tuberculosis, is very un- 
favorable. The consequences to be feared are postpartum 
hemorrhages on the one hand, rapid loss of strength and 
exacerbation of the systemic disease, and pulmonary 
edema on the other hand. 

Influenza is often followed by septic infection (metritis, 
peritonitis) and the discharge of fetid lochia, even in 
cases in which there has been no vaginal exploration nor 
even support of the perineum during labor. Similar 
danger exists in the case of erysipelas, and the prognosis 
of labor is even more unfavorable. 

The sequels of chronic nephritis in the case of the 
parturient, and much more rarely of the puerperal, woman 
in the form of eclam])sia and its treatment have been 
discussed in § 13, in connection Avith Premature Labor. 

The influence of disturbances of innervation upon labor mani- 
fests itself in various ways, and is much more extensive and of 
more frequent occurrence than might be supposed from the 
cursory manner in which the subject is usually treated in text- 
books in the chapter on Anomalies of Labor-pains. Disturb- 
ances in the form of simple neuroses are of serious import for 
two reasons: either they may, like hyperemesis gravidarum, be 
followed by serious consequences to the child and occasionally 
to the mother; or, on the other hand, they may, by simulating 
alarming symptoms, induce the beginner to resort prematurely to 



276 PATHOLOGY OF LABOR. 

active interference and thereby expose the woman to the dangers 
of injury. Again and again men of the widest experience, like 
V. Winckel, who learned their profession during a period when 
any form of unnecessary interference was discountenanced, have 
insisted that every beginning practitioner should seize every op- 
portunity to observe physiological labors as accurately as pos- 
sible, and this dictum still retains all its force even in these days 
of antisepsis, anesthesia, and improved technique. Accurate 
recognition of any deviation from the physiological process dur- 
ing labor is the only protection against harmful interference, 
especially now that we have acquired a knowledge of the nervous 
pheni)mena. 

Among the causes of functional anomalies in the innervation 
the author has, above all, observed alterations in the type of the 
labor-pains. In addition to the subjective symptoms of increased 
pain, localized especially near the sacrococcygeal extremity or in 
one horn of the uterus, the effects of such nervous disturbances 
manifest themselves objectively in the diminution of the force of 
the contractions. In neuropathic individuals not suffering from 
any special gynecological disease very painful gestation pains 
often make their appearance during the last six to ten weeks, 
occurring usually at night, associated with profuse sweating. 
During parturition, which may be premature or abnormally 
delayed, the severity of the pains becomes abnormally in- 
creased, and the contractions, which are manifestly asymmetrical 
and may even partake of the partial tetanic type, fail to bring 
about sufficient dilatation of the external os, which is often de- 
layed for hours or even for days without any apparent reason. 
Premature rupture of the atnniotic sac without endometritic 
symptoms is a very common occurrence. If the abdominal walls 
are relaxed, the head may become lodged in a sacculation and be 
completely arrested above the superior strait, in spite of the 
vigorous contractions of the uterus lasting for hours or even days. 
This probably occurs only in muitiparse : the cervical canal offers 
an obstinate resistance to the dilating force for twelve or even 
twenty-four hours, although after version has been performed it 
distends readily enough ; there is no true stricture at the internal 
OS. Even during the expulsive period the progress of labor may 
be arrested if the os fails to dilate and is forced down into the inter- 
spinal line by the pressure of the head, which is unable to perform 
complete rotation. This complication of persistent transverse posi- 
tion of the head is partly dependent on stenosis or, at least, rigidity 
of the lower portions of the birth-canal and is, therefore, particu- 
larly liable to occur in elderly primiparse, with vaginismus or with 
coiling of the umbilical cord. In addition, other clonic and 
tonic muscular spasms (gastrocnemius) and frequent reflex attacks 
of vomiting, ptyalism, hyperidrosis, anidrosis, severe attacks of 



ANOMALIES IN THE LABOR-PAINS. 277 

migraine and neuralgia, may occur during pregnancy and labor. 
The author has observed a whole series of local and reflex 
nervous symptoms in a multipara during several successive de- 
liveries. During the height of the labor-pains, which were un- 
duly protracted, clonic fibrillar contractions of the extremities 
and tic convulsif made their aj)pearance; in another multipara 
the labor-pains during several deliveries were accompanied by 
deep-seated, continuous, spasmodic sacral pains and by stenocardia 
and pain in the subscapular region. Temporary sciatica and 
neuralgia of the obturator nerve are not infrequent. The nervous 
symptoms are apt to be exaggerated during influenza. 

On the other hand, labor-pains may come to a complete stand- 
still either before or after complete dilatation of the os, especially 
after premature rupture of the membranes. A concomitant 
symptom is " atony of the abdominal pressure," which is partly 
dependent on hysterical abulia. 

After the birth of the child we often observe excessively dis- 
tressing afterpains, and in primipar^e sometimes a constant sore- 
ness of the coccyx which may last for several days. In the third 
stage irregular pains of partially tetanic and constricting character 
lead to unequal separation of the placenta or to its retention 
within the body of the uterus. Excessive afterpains may be 
hereditary and have been observed to occur in several generations 
(Skutsch) ; the author observed a case of this kind which was 
associated with migraine. 

This mixture of hyperesthesia, atony, and partial tetanic phe- 
nomena extends to the adjoining organs, as the bladder, for 
instance. Catheterization during labor and the puerperium is 
extremely painful, so that occasionally ischuria may persist an 
entire week in spite of every attempt to relieve it (hot applica- 
tions and douches, psychical suggestion), and in the absence of 
all objective findings. Similar phenomena come to the notice of 
the gynecological operator. This brings us very near the domain 
of disturbances of ithe central nervotis system which may lead to 
psychoses resembling hysterical manifestations. 

Multiparae with defective innervation of the abdominal parietes 
and of the pelvic organs often suffer from Inchiometra during the 
first days of the puerperium and, occasionally, from fever lasting 
twenty-four hours ; the amount of blood and secretion discharged 
is increased, while, on the other hand, the milk secretion often 
fails to appear or disappears suddenly, and the abdomen becomes 
swollen. In this connection we must also refer to the marked 
individual variations in the frequency of the pulse during the 
puerperium. 

When we come to pathological alterations in the domain of the 
nervous system susceptible of objective demonstration, as neu- 
ritis, multiple neuritis, and myelitis, etc., we find that their con- 



278 DIAGNOSIS AND TREATMENT. 

sequences are very much better known. In myelitis with total 
loss of the power of motion and sensation in the lower extremi- 
ties, the complete development and expulsion of the fetus have 
been repeatedly observed without the occurrence of any subjective 
sensation of pain and without the exertion of the abdominal 
muscles, and this also has been frequently confirmed by physio- 
logical experiments. 

The clinical picture of neuritis gravidarum and puerperalis is 
the same as that of any other neuritis : complete or partial loss 
of motor-power with atrophy of the muscles, tenderness of the 
nerve-trunks and paresthesi^e, especially a feeling of numbness in 
the fingers and toes and distressing formication. Occasionally 
multiple neuritis and hyperemesis make their appearance toward 
the end of pregnancy in combination with hemorrhages from the 
uterus. The possible causes are : 

(a) Mechanical pressure naturally showing itself only in the 
lower extremities after difiicult extractions ; 

{b) Intoxications, including auto- or metabolic intoxications, 
which often occur during pregnancy and may be associated with 
hyperemesis, and infections which gradually extend to all the 
nerves and in which the prognosis is very unfavorable. Possibly 
a further cause may be found in the excessive use of disinfectants. 
The treatment consists in baths and massage during gestation, 
and in electricity, but only during the puerperium. Windscheid 
even goes so far as to suggest the induction of premature labor in 
severe cases. The same rules of treatment apply as in hyper- 
emesis. 



CHAPTER YIII. 

GENERAL REMARKS ON EXPLORATION FOR 
PURPOSES OF DIAGNOSIS AND TREATMENT. 

A SCHEME of the various dangers to mother and child during 
labor constituting an indication for operative interference has 
been given in | 23. 

The general rules to be observed in preparing the patient are 
described in ^ 2. 

? 24. PREPARATION OF THE PATIENT FOR EXAMINA- 
TION AND INSTRUMENTAL DELIVERY. 

If the physician is called to attend a labor in which he 
has any reason to suspect one of the above-described 



PREPARATION OF THE PATIENT. 279 

complications, he should at once take the woman's tem- 
perature. Meanwhile he should make his inquiries in 
regard to age, the possible occurrence of rachitis during 
infancy, or the presence of any other organic disease 
which might affect labor, the course of former deliveries, 
the date of the last menstruation, and the course of the 
labor which he is about to attend. He next proceeds to 
confirm and supplement the information he has obtained 
by means of objective examination (see § 2), paying par- 
ticular attention to the condition of the bladder. Internal 
examination must be preceded by careful disinfection, 
according to the rules given in § 2. 

In the mean time the nurse should scrub the vulva, 
first with soap and then with a 1 per cent, lysol or 3 per 
cent, carbolic-acid solution, and, if necessary, shave the 
perineum and the lower half of the labia, and evacuate 
the rectum, unless it has been previously emptied. This 
should be done if possible with the woman lying cross- 
wise on the bed. Next the catheter is introduced and the 
vagina flushed out and thoroughly rubbed w^ith a 1 per 
cent, solution of lysol after the nurse has once more care- 
fully cleansed her fingers with a brush. The cleansing 
of the vagina may be omitted unless an internal examina- 
tion has been made by some one else or the vaginal 
secretion has a suspicious odor and a slightly viscid con- 
sistency. 

Instruments, catheters, glass tubes, etc;., are to be care- 
fully boiled and then placed in a 3 per cent, solution of 
carbolic acid. Zweifel's douche-bag is placed in the same 
solution. 

The following articles should be laid out in readiness : Two 
basins for the use of the physician to wash and disinfect himself, 
one basin with carbolized water for the instruments, one vessel to 
boil the instruments, clean towels and bed-sheets, one pail and 
another basin or other vessel instead of an irrigator for the douche- 
bag. Every receptacle to be thoroughly boiled. 

tJterine irrigations after delivery with 2 to 2J per cent, carbolic- 
acid, or 1 per cent, lysol or cresol solution*, are performed with the 
aid of a speculum in the portio vaginalis, and a two-way catheter 



280 DIAGNOSIS AND TREATMENT. 

(Fritsch-Bozeman). They are to be practised, however, only if 
the possibility of infection is suspected on account of previous 
examination or of operative interference. The point of the cath- 
eter is guided with the finger until the fundus is reached — i. e., 
beyond the contraction-ring, which must be carefully felt for. 
The tube of the catheter should not contain air, but should be 
filled with sterile water, and the antiseptic solution is not to be 
poured in until the operator is certain that a continuous flow is 
established. In the same way the entrance of air should be 
guarded against at the end of the irrigation. 

The physician now makes a careful examination of the 
pelvis, ascertaining its form, the extensibility of the soft 
parts, especially the degree of dilatation of the os, the 
position of the child, and the progress made by the pre- 
senting part ; for instance, in what diameter of the pelvis 
the sagittal suture is found, whether the anterior or poste- 
rior fontanel is deeper, or whether there is a presentation 
of the posterior parietal bone, etc., and, finally, whether 
there is any danger for mother or child (see § 23). 

So-called diminution in the force of the labor-pains is 
rarely an indication for the use of forceps. 

We have, therefore, three questions to answer: (1) Is 
there any indication for interference ? (2) What operation 
is indicated ? (3) Has the proper moment arrived ? The 
proper moment is determined by the position of the head 
and the degree of dilatation of the os. Internal version, 
forceps, and craniotomy require a dilatation sufficient to 
allow the passage of the presenting part, and if that 
degree of dilatation has been reached, the time for opera- 
tion has come. The application of forceps is indicated if 
the head is firmly fixed ; craniotomy only when the head 
has descended far enough. 

All operations are to be performed with the most scru- 
pulous antiseptic precautions, and with the patient lying 
crosswise on the bed with the legs supported on two chairs 
and the back well raised by means of pillows, or on a 
table. The woman is placed in the lateral position only 
when version is to be performed, on the side corresponding 
to the position of the feet. If the woman is lying on her 



THE INSTRUMENTARTUM. 



281 



left side, the operator uses his right hand for internal 
manipulation, introducing it at the end of a labor-pain. 

The chloroform is dropped at regular intervals on the 
inhaler until narcosis is complete, and the woman is then 
kept on the boundary-line between anesthesia and con- 
sciousness. The bladder must be emptied before the 
beginning of the operation. 



§ 25. THE INSTRUMENTARIUM. 

The instrument-bag should be made of some material 
which can be readily disinfected, such as canvas or metal, 
and contain two compartments^ one of which {A), also made 
of canvas, contains the drugs and the smaller instruments, 
including those which need not be disinfected^ while the 
other (5), which can be sterilized, being made of metal or 
linen, after Fritsch's method, contains the instruments 
which require sterilization. 



A contains : 

Suturing Apparatus. 

1. Needles: several strong, 
curved needles in a tin box. 

2. Needle-holder. 

3. Silk sterilized in steam and 
kept in envelopes or boiled in 5 per 
cent, solution of carbolic acid and 
kept in alcohol. Silkworm gut in 
carbolic acid. 

4. Catgut sterilized by dry heat 
or in oil of juniper and kept in 
alcohol. 

5. Tenaculum forceps. 

6. Several pairs of forceps with 
a sliding catch (Schroder). 

7. Several K5berle forceps or 
small hemostatic forceps (Pean) or 
clamp force])S. 

8. A Dechamps needle, curved 
and provided with a handle. 

Sti rgical Instruments . 

9. Scalpel. 



11. A pair of Cowper's curved 
scissors. 

12. Apairof long, heavy Siebold's 
scissors. 

13. A pair of forceps 1 foot (30 
cm.) long. 

14. A Cusco or Sims' speculum. 

15. A curette. 

16. A razor. 

17. Two bullet forceps. 

18. Two long, heavy hemostatic 
forceps (clamp forceps). 

Anesthetics. 

19. 4 tl. oz. (150 gm.) chloroform 
in a dark bottle. 

20. An Es march inhaler. 

21. A pair of delicate Muzeux 
forceps or other tongue forceps. 

Tamponade and Dilatation. 

22. A thin-walled colpeurynter. 



10. A probe-pointed 
with a long handle. 



bistoury 



23. 
cen fc. 

24. 

25. 
ceps. 



Iodoform gauze, 10 to 20 per 

Salicylated cotton. 

A pair of long dressing for- 



282 



DIAGNOSIS AND TREATMENT. 



Infusion. 

26. A heavy infusion needle with 
rubber tube and funnel, or a syr- 
inge. 

27. Several packages containing 
0.6 NaCl or Feis' tablets. 

Antiseptic Preparations. 

28. Ih oz. (50 gm.) liquid carbolic 
acid in alcoholic solution. 

29. Twenty tablets 0.5 sublimate 
(Angerer's or Pieverling's hydrarg. 
oxycyanat. tablets) ; spiritus vini 
rectif. (alcohol). 

30. 1 oz. (25 gm.) lysol for 1 per 
cent. ly.sol solution, instead of vase- 
line. 

31. A glass graduated up to 1 fl. 
oz. (30 gm.). 

Various Drugs. 

32. Camphor. 

33. 2 fl. oz. (50 gm.) aether, sul. 

34. Morphine hydrochlorate (3 
gr. [0.2 gm.] : 160 TT^ [10 gm.] of 
water) ; syringeful = ^ gr. (0.02 
gm.) morphine 4- atropine. 

35. +0Z. (15 gm.) chloral hydrate, 
divided into ten powders. 

36. 2 fl. oz. (50 gm.) tincture the- 
baica (20 to 30 drops a dose). 

37. Ergotin or cornutin. 

38. 2 per cent, solution argentic 
nitrate. 

39. 2 fl. oz. (50 gm.) liquor ferri 
sesquichloridi. 

40. Mustard leaves. 

Various Instruments, etc. 

41. Stethoscope. 

42. Thermometer. 

43. Two nail-brushes. 

44. One elastic Charriere cathe- 
ter, No. 12. 



45. Eubber apron. 

46. Tape-measure. 

47. Towel and soap. 

B contains : 

Obstetrical Instruments. 

1. A Nagele's forceps. 

2. Cranioclast or cepnalotribe. 

3. A Nagele's perforator. 

4. A Mesnard-L. Wiuckel's bone 
forceps. 

5. A loop of wide, heavy silk 
tape (round cord, after Ziegen- 
speck, is the best). 

Irrigation, Injection, and Catlieteri- 
zation. 

6. Irrigator with rubber tube or 
Zweifel's douche-bag. 

7. Eectal tube. 

8. Vaginal tube of glass with 
slight curvature. 

9. Fritsch-Bozeman's uterine 
catheter of large caliber. 

10. Two medium-sized elastic 
male catheters (Nos. 9 and 10). 

11. A silver female catheter. 

12. A Pravaz syringe. 

Between these two compart- 
ments, that is to say, in the body 
of the bag itself, a Baudelocque- 
Martin's pelvimeter is stowed (see 
Fig. 43), or a Gomann's collapsible 
pelvimeter. If necessary, the large 
cranioclast and the cephalotribe 
may also be placed in this part of 
the bag. 

Prussian^ midwives must have 
the following articles in their bags 
in addition to their personal toilet 
articles : 

An instrument-ease with 1, 3 oz. 
(90 gm.) liquid carbolic acid ; 2, a 
graduated glass to measure i oz. 



^ The bag of the Bavarian midwife contains in addition a second vagi- 
nal glass tube, a rectal tube made of hard rubber, a medium-size rectal 
syringe, an elastic female catheter, a rubber nipple with a glass base, 1 
oz. (30 gm.) of ether, tincture of cinnamon, oil of almonds, a fillet for 
performing version, tampons of salicylated cotton in bulk. On the other 
hand, it does not contain soap and towel, a metal rectal tube, Hoffman's 
anodyne drops, and silver-nitrate solution. 



PUERPERAL FEVER. 



283 



and 1 oz. (15 aud 30 gm.) carbolic 
acid; 3, soap, nail-biusli, aud 
towel ; 4, an irrigator of one quart 
(liter) capacity with a mark at 1 
pint (h liter) and provided witii a 
rubber tube from 1 to 1| yds. (1 to 
1.5 meters) loug ; 5, a glass tube 
for the vagiua; 6, a metal rectal 
tube ; 7, a metal female catheter ; 
8, a cord cutter ; 9, a narrow lineu 
tape ^ in. (0.5 cm.) wide for tying 
the umbilical cord ; 10, a package 
with twelve balls of clean cotton, 
the size of a lien's agg, tied with a 
thread aud preserved in white 



parchment paper and the whole iu 
a bag of some white material ; 11, 
vaseline; l:i, Hoffman's anodyne; 
13, dark glass medicine-dropper 
with 2 per cent, argentic nitrate 
solution; 14, clinical thermome- 
ter ; 15, bath-thermometer.' 

The instruments are sterilized 
before and after use by boiling 
them for from fifteen to thirty 
minutes in a 3 per cent, carbolic- 
acid solution, or they may be ster- 
ilized by dry heat up to 302° to 
338° F. (150° to 170° C). 



CHAPTER IX. 



PATHOLOGY OF THE PUERPERIUM. 
§ 26. PUERPERAL FEVER. 



Owing to the peculiar mode of introduction and propagation 
of micro-org-anisms, puerperal infections present certain charac- 
teristic clinical pictures which depend on alterations in the cir- 
culatory apparatus, on the presence of definite lesions, and of 
typical physiological wounds and their secretions. These clinical 
pictures are very complex and their classification from either the 
anatomical or the bacteriological standpoint is somewhat difiicult. 
While giving the usual scheme of classification, I shall confine 
myself in the text to the description of the clinical pictures which 
are most commonly observed at the bedside. 

The cause of puerperal fever is found in the invasion of the 
excoriated cavities of the genitalia by pathogenic bacteria, 
although other predisposing causes, such as cold, dietetic errors, 
emotional excitement, and hemorrhage may indirectly assist the 
invasion and extension of the micro-organisms by diminishing 
the resisting-power of the body. 

^It is often important for the physician to know what he can find in 
case of necessity in a midwife's bag, but it is to be remembered that any 
operator who really desires strict antisepsis will often be very skeptical 
as to the condition of the contents of such a bag, especially as the mid- 
wife is required to supply the materials herself in pauper practice. In 
Baden a law has recently been passed which requires midwives to get 
all their drugs and tampon material from the drug-stores. 



284 PATHOLOGY OF THE PUEBPEBIUM. 

Anatomical Classification. 

(1) Ulcers on the vulva, vagina, and portio vaginalis. 

(2) Vulvitis, colpitis, acute simple endometritis. 

(3) Acute metritis and salpingitis. 

(4) Paracolpitis and parametritis, pelvicellulitis. 

(5) Perimetrosalpingitis, peritonitis. 

(6) Phlebitis, metrophlebothrornbosis. 

Bacteriological Classification. 

(1) Pyogenic organisms in the secretions of the uterine cavity. 

(2) Micro-organisms are found on the excoriated surfaces 
(grayish ulcers). 

(3) The micro-organisms are found in the mucous membrane. 

(4) The micro-organisms penetrate through the deeper lym- 
phatic vessels into the connective tissue (parametritis). 

(5) Infection of the tube or of the peritoneum through the 
same channels (peritonitis). 

(6) The micro-organisms themselves find their way into the 
circulation and spread to the entire body (general septicemia). 

(7) The products of the micro-organisms (sepsins and ptomaius), 
especially of the microbes of putrefaction, find their way into the 
vascular channels (sapremia). 

(8) Infection of the venous thrombi with secondary pyemic 
emboli in the circulation (pyemia). 

(9) The principal bacteria concerned in these various forms of 
disease are the Streptococcus pyogenes. Staphylococcus aureus 
and albus, Bacterium coli, the pneumococcus and gonococcus, 
the tetanus bacillus, and saprophytes. 

CliniGally, we distinguish the following conditions : 

(1) Ulcers of the vulva, vagina, and ])ortio vaginalis. 

(2) Acute simple puerperal colpitis and endometritis. 

(3) Metritis and parametritis (paracolpitis). 

(4) Metrolymphangitis, or salpingitis, and peritonitis. 

(5) General fulminating puerperal septicopyemia. 

(6) Sapremia. 

(7) Metrophlebothrombosis and pyemia. 

(1) Puerperal Diphtheritic Ulcers of the Vulva, "Vagina, 
and Portio Vaginalis. — Diagnosis. — The ulcers corre- 
spond in position with the sites of the most frequent 
lesions during labor, i. e., the nymphse, the posterior sur- 
face of the vestibule, the lower portion of the vagina, the 
vaginal vault, and the external os. The excoriations and 



PUERPERAL FEVER. 285 

fissures begin to secrete a thin pus during the first twenty- 
four hours, the floor of the ulcers is covered with a 
vellowish-o;rav exudate, and the edo-es become inflamed 
and painful. The aflected parts are edematous. In rare 
cases a phlegmonous condition develops and a deep ab- 
scess is formed in the connective tissue. Phlebectasia 
and gonorrhea are predisposing factors. 

Symptoms. — Pain and burning sensation during micturi- 
tion, fetid lochia, remittent fever with chills, ischuria. A 
careful inspection should be made. 

Treatment. — If there is any reason to suspect puru- 
lent endometritis before labor, the vagina should at once 
be irrigated with a 3 per cent, solution of carbolic acid 
or a 1 per cent, solution of lysol as sl prophylactic measure. 
If ulcers are present they must be touched with chloride 
of zinc or ferric chloride and dressed with itrol (silver 
citrate) or iodoform (iodoformogen and europhen), or com- 
presses of aluminium acetate, or, if the granulations are 
flaccid, the old-fashioned turpentine dressing may be 
employed. 

(2) Acute Simple Puerperal Colpitis and Endometritis. — 
Diagnosis. — On careful examination with the speculum 
the papillae on the vaginal mucous membrane are found 
to be very prominent ; the entire region is swollen, red- 
dened, and bleeds on the lightest touch. The lips of the 
external os are swollen and edematous and covered with 
exuberant granulations which bleed at the slightest con- 
tact. The portio vaginalis and the cervical mucous mem- 
brane, which is also very hyperemic and secretes an 
abundant mucopurulent and bloody fluid, are covered 
partly with the ovulse Xabothi, partly with prominent 
papules, which when incised are found to contain pus. 
In the rare cases that come to the autopsy-table the same 
condition was found in the mucosa of the body of the 
uterus, especially at the placental site. The whole mass 
of swollen mucous membrane can be readily separated 
from the edematous but well-contracted muscular layer, 
and is found to be full of ecchvmoses. 



286 PATHOLOOY OF THE PUEBPERIUM. 

Symptoms, — The lochia are often fetid and streaked 
with blood ; the fever is quite high and remittent in char- 
acter, short chills alternating with a feeling of heat; 
afterpains are severe and persistent ; the uterus is slightly, 
the abdomen not at all, sensitive. Later there may be 
hemorrhage on account of incomplete involution of the 
placental site, and the condition may go on to chronic 
endometritis and uterine displacement. 

Etiology. — Injuries ; the existence of catarrh previous to 
gestation ; faulty aseptic technique in suh-partu explora- 
tions ; decomposing })orti()ns of the fetal membranes. 

Prognosis. — The fever lasts from three days to a week 
with a tendency to relapses. The inflammation is apt 
to become chronic and there is danger of extension to 
deeper tissues or to the tube and the perimetrium. The 
condition is often complicated with subinvolution of the 
uterus, and may be followed by a whole series of gyne- 
cological troubles. 

The course, as in all these diseases, depends on the 
virulence of the micro-organisms and the resisting-power 
of the genitalia and of the entire body to the action of 
bacteria. 

Treatment. — Priessnitz compresses; ergotin ; vaginal 
irrigation, repeated several times a day ; mild laxatives 
(calomel gr. ss to iss [0.03 to 0.1 gm.] three or four times 
a day). If the hard and painful condition of the uterus 
persists, vaginal irrigations ; intra-uterine douche, once 
repeated, with weak antiseptic solutions (not with subli- 
mate) ; or cauterization with concentrated carbolic acid. 

(3) Acute Puerperal Metritis and Parametritis (Paracol- 
pitis). — By metritis is meant an inflammation of the peri- 
vascular and interstitial connective tissue of the muscu- 
laris, originating in excoriations or ulcers in the uterine 
cavity, and directly caused by the Streptococcus pyogenes. 
The inflammatory process spreads to the connective tissue 
outside of the uterus, and from that point successively 
involves the tissues by the side of the bladder and the 
extraperitoneal connective tissue in the abdominal walls, 



PUERPERAL FEVER. 287 

or even of the upper part of the thigh, or it may spread 
laterally between the two layers of tiie broad ligament to 
the iliac bones, or extend backward behind the peritoneum, 
pushing up Douglas' pouch and involving the psoas 
muscles or even the kidneys. 

These processes are included under the terms jxtra- 
mctritis (Virchow) or i^ehio cellulitis (phlegmon of the 
pelvis, pelvic exudate), and consist in a gelatinous swell- 
ing and round-celled infiltration of the connective tissue 
(see illustration in Atlas of Gynecology). A mass of exu- 
date which often attains the size of a man's head grad- 
ually accumulates, usually to one side of the uterus and 
later slowly undergoes absorption, leaving firm indura- 
tions in the parametric connective tissue, which later pro- 
duce pathological fixations and displacements of the 
organ. AYhile this is the usual course, the exudate may 
break down and the pus may be discharged into the 
rectum, into the vagina, into the bladder, through the 
ischiatic foramen along the inguinal canal, or directly 
through the abdominal wall above Pou part's ligament. 
Recovery then takes place unless the peritoneum has 
given way, in which case fatal peritonitis develops. Oc- 
casionally the process involves the opposite side sec- 
ondarily. 

Symptoms. — During the first week after labor there 
is generally considerable fever with chills and abdominal 
pain. In a few days, as the exudate accumulates, the 
patient complains of pain in the loins and kidneys and 
of pain and loss of power in the leg ; urinary symptoms 
are sometimes present (paracystitis). The lochia are 
often fetid and may become bloody again owing to the 
subinvolution of the uterus. The fever gradually as- 
sumes a remittent and then an intermittent type Avith 
frequent relapses. If the fever becomes hectic and fre- 
quent chills take place, it is a sign of abscess-formation ; 
as soon as perforation occurs the fever disappears. 

Diagnosis. — As soon as fever and pain make their ap- 
pearance the sensitiveness of the abdomen and the con- 



288 PATHOLOGY OF THE PUERPERIUM. 

dition of the lochia must be carefully examined. The 
pain in the abdomen may be circumscribed if there is a 
local irritation of the serous membrane, but the entire 
surface of the abdomen is never jjainful and tumid nor 
is there any peritoneal exudation. On the other hand, it 
is often possible from the very first to detect an area of 
tenderness and later of resistance to one side of the 
uterus, until finally a tumor of doughy consistency is dis- 
tinctly palpated. The vaginal vaults and the portio 
vaginalis become obliterated. 

The diagnosis is somewhat simplified by the 'fact that 
the exudate does not spread along the peritoneum, but 
downward along the vagina or to Poupart's ligament. 
For the differential diagnosis from tumors in the pouch 
of Douglas, see under Ovarian Cysts, Extra-uterine Preg- 
nancy, Myomata. 

Prognosis. — The prognosis is rarely unfavorable as to 
life, although from six to eight weeks usually elapse be- 
fore the woman recovers. If an abscess forms, as happens 
in about 15 per cent, of all cases, the pain is intense and, 
owing to the severity of the fever, loss of strength is ex- 
treme and convalescence very slow. If the woman is 
delicate, it is better to tell the family at once that the 
patient will probably have to be confined to her bed for 
months. 

Treatment. — If the abdomen is very painfid, ice-bags, 
Priessnitz compresses. Absolute rest in the dorsal posi- 
tion. Enemata; calomel several times a day, from gr. 
viij to xxiv (0.5 to 1.5 gm.) ; castor oil. To promote 
absorption : inunctions with mercurial ointment, gr. xv 
(1 gm.) of the ointment mixed with an equal amount of 
vaseline every two hours until salivation is produced, or 
potassium-iodide ointment may be substituted. The 
fetid lochial discharges and the ulcers on the vulva or 
portio vaginalis, if any are present, are to be treated in 
accordance with the principles laid down under acute 
endometritis. Fluctuating abscesses in the abdominal 
wall, in the vagina, or in the rectum should be opened ; 



PUERPERAL FEVER. 289 

in the latter, with the aid of a trocar. In addition kike- 
warin or warm baths should be given ; the diet should 
be light but nutritious. If there is diarrhea, bismuth 
subnitrate and morphine or thebaine are indicated ; the 
last-mentioned drug has a certain bactericidal action. 

(4) Septic Metrolymphangitis. Acute Puerperal Salpin- 
gitis and Peritonitis. — In nearly all the cases the strepto- 
cocci effect an entrance through grayish-yellow fissures 
and ulcers in the genital tract and in the placental site. 
The infection is usually unilateral and extends from the 
ulcerated endometrium through the swollen lymph-chan- 
nels and enlarged and suppurating lymphatic glands into 
the muscularis and thence into the subserous tissue. The 
affected tissues rapidly break down and, along with the 
most prominent portion of the serous membrane, become 
necrotic, thus leading to peritonitis. The serous mem- 
brane is the seat of inflammatory hyperemia. The true 
pelvis is filled with masses of exudate ; the boAvels are 
filled with gas, and loops of intestine become matted to- 
gether. The fluid exudate may spread beyond the cul- 
de-sac of Douglas ; and gradually all the various organs 
of the body become involved in the infectious process : 
pleuritis and pericarditis develop. Occasionally the proc- 
ess remains localized near the spot Avhere rupture of the 
peritoneinn first took place, which is usually in Douglas' 
pouch (circumscribed peritonitis). 

The virus also makes its -way through the lymphatic 
channels to the ovaries, the walls of the tube, and the 
bladder, so that abscesses form in these localities. Rupt- 
ure of an ovarian abscess may in this way give rise to 
peritonitis. 

Finally, the virus may be conveyed to the peritoneum 
along an inflamed Fallopian tube — i. e.^ by an endosal- 
pingitis, the pus making its way into the abdominal 
cavity, usually on both sides : pelveoperitonitis. If, as 
sometimes happens, the abdominal opening of the tube is 
closed by adhesions, a pus-tube may form and rupture 
later on. 

19 



290 PATHOLOGY OF THE PUERPERIUM. 

Symptoms. — The condition begins with a violent, pro- 
tracted chill, which is soon followed by intense pain over 
the entire abdomen, elicited by movement, respiration, and 
by palpation, especially of the uterus, which is hard and 
enlarged. The congestion in the vessels of the head shows 
itself in flushing of the face and vertigo ; later somnolence 
and delirium make their appearance, and may even go on 
to mania. 

There is a rapid rise in the temperature accompanied 
by considerable acceleration of the pulse and of respira- 
tion. The presence of an exudate in the peritoneal cavity 
can often be detected by percussion as early as the first 
day. The abdomen is tympanitic and very much swollen 
on account of the great accumulation of gas in the intes- 
tines, due partly to the paralyzing effect of the fever on 
the muscular wall and partly to the intestinal inflamma- 
tion. Tenesmus and vomiting also occur, as pressure is 
exerted on the diaphragm as well as on the abdominal 
walls ; dyspnea soon develops and later becomes more 
marked as the pleura participates in the inflammation. 

The secretions of the body are diminished in quantity ; 
there is vesical tenesmus and the urine is concentrated and 
of high specific gravity. It may contain albumin. At 
first there is constipation, which later is followed by diar- 
rhea. The lochia, which are also diminished in quantity, 
have a fetid odor and contain many pyogenic cocci, found 
in the decidua cells and in the blood-corpuscles. The 
milk secretion is also diminished in quantity. 

If the lymphatic septic peritonitis runs this aaute 
course, the crisis may occur within eight days and con- 
valescence gradually begin, or the patient succumbs to 
the exhaustion. If the exudate is not absorbed and the 
patient lives, perforation of one of the hollow organs or 
of the parietal walls may take place, and the exudate be 
discharged ; in this event secondary sloughing of intes- 
tinal origin may occur. 

Circumscribed peritonitis runs a chronic course. The 
disease in the serous membrane progresses slowly, being 



PUERPERAL FEVER. 291 

constantly shut off from the rest of the peritoneal cavity 
by the formation of adhesions, jUvSt as in ovarian abscess. 
This form of peritonitis is described as pyofibrinous. It 
leads to pathological fixations and displacements of the 
uterus and to chronic inflammatory processes. 

Diagnosis. — The presence of an intraperitoneal exu- 
date is determined by percussion and rectal palpation, the 
diagnosis being confirmed by the existence of tenderness 
and swelling of the abdomen. The rupture of an abscess 
is detected by examining the urine, feces, etc. 

For the differential diagnosis from parametritic exudation and 
retro-uterine tumors, see under Puerperal Parametritis, Ovarian 
Cysts, etc. 

Treatment. — See below. 

(e5) Fulminating Puerperal Peritonitis. Septicopyemia. — 
If large numbers of very virulent germs suddenly pene- 
trate into the peritoneal cavity, owing to rupture of the 
uterus, rupture of a pus-cavity, or the discharge of septic 
pus from the abdominal orifice of a tube, the course is so 
rapid that there is no time for an elevation of temperture ; 
the patient immediately goes into a cachectic state, the 
pulse and respiration are enormously accelerated while the 
temperature falls. The symptoms are somnolence, rapid 
swelling of the abdomen with an enormous amount of 
exudation, pain, singultus, vomiting, diarrhea, and invol- 
untary passage of urine and feces. The expression of the 
face is that of approaching dissolution, although the mind 
may remain clear and the patient be cheerful to the end. 
Death almost always occurs in from twelve to forty-eight 
hours. For the treatment see below. 

(6) Gangrenous Peritonitis. Sapremia. — If, as a result 
of pressure-necrosis, a part of the uterus or of the fetus 
becomes gangrenous, or rupture takes place from an 
encapsulated focus of decomposition or from the intestine, 
the entire peritoneum breaks down into a brow^nish semi- 
fluid mass. 

Symptoms. — Rapid development of meteorism, high 
fever, and somnolence. The condition usually follows a 



292 PATHOLOGY OF THE PUERPERIUM. 

severe spontaneous or instrumental delivery complicated 
by localized pressure-necrosis. 



TREATMENT OF ACUTE PELVEOPERITONITIS (METRO- 
LYMPHANGITIS AND SALPINGITIS). 

As soon as tenderness develops in the abdomen and the 
intestines become distended, a Priessnitz compress should 
be applied. Calomel, g\\ iss to v (0.1 to 0.3 gm.), and 
rectal enemata with vaginal and intra-uterine irrigations 
are indicated. The latter are to be avoided in salpingitis, 
lest tubal contractions be induced. If ulcers are present 
they should be cauterized. 

If there are marked symptoms of peritonitis, such as 
increase in the exudate or excessive tenderness and vomit- 
ing, several ice-bags should be applied to the abdomen as 
long as the fever lasts. At first laxatives may be given, such 
as inf. sennse comp. and calomel (at first gr. iij to viij [0.2 
to 0.5 gm.], later gr. |- to iss [0.05 to 0.1 gm.] at a dose). 
For meteorism, fennel, hydrochloric acid, or sulphur 
internally, or oil of turpentine, ^ss to j (15 to 30 gm.), 
per rectum. Profuse diarrhea may be checked with small 
doses of tincture of thebaine. To combat the vomiting, 
ice-pills and rectal infusions of normal salt solution. The 
diet should be liquid or semisolid : soup, milk, eggs, 
calves'-foot jelly, scraped meat, the various peptones and 
hemoglobin preparations, beef-tea. 

The patient must be freely stimulated with brandy, 
egg-no^, champagne, claret (Runge gives large doses : 
ffv [150 gm.] cognac, half a bottle of claret per day), in 
order to guard against excessive loss of strength and 
cardiac failure, but only when the patient is used to wine 
and beer. Other stimulants may also be given, such as 
camphor internally and hypodermatically, ether, bouillon. 
Diaphoresis should be promoted, and infusions of deci- 
normal salt solution administered. 

For pleuritis a mustard-plaster and dry cupping ; for 
exhausting diarrhea, chlorine- water in an equal quantity 



TREATMENT OF SEPTICEMIA AND SAPREMIA. 293 

of distilled water, one tablespoonful every two hours, and 
emollient beverages. 

It* the peritonitis is due to rupture of the uterus or 
vagina, the fetal portions that have escaped are to be 
removed and the wound drained with iodoform gauze. In 
this case opium may be employed. 

If it is desired to supplement the administration of 
calomel by a general mercurial treatment, sij (8 gm.) of 
blue ointment mixed with an equal quantity of vaseline 
may be rubbed in every day until salivation is produced 
(gr. XV [1 gm.], every two hours for about a week). The 
same effect may be produced by the inunction of the silver 
salts in the form of ointments (Crede). 

In the lymphatic form diaphoretic remedies may be 
employed with good results (Kehrer) : aromatic tea with 
warm pack, camphor and liquor ammonii acetatis (the 
kidneys must be watched) with morphine and small doses 
of quinine or lukewarm baths; this must also be supple- 
mented by alcoholic stimulation and nutritious diet. As 
soon as fluctuation is detected, and the wall of the vagina 
or of the abdomen begins to bulge, the abscess should be 
opened and drained with iodoform gauze. 

TREATMENT OF GENERAL SEPTICEMIA AND 
SAPREMIA. 

The treatment of septicemia consists in encouraging 
diaphoresis bv means of baths at a temperature of from 
80° to 88° 1^(26.6° to 31.1° C). The bath should last 
not longer than five minutes, the patient being carefully 
watched and stimulated with alcoholic beverages during 
and after the bath, as directed above. The food should 
be rich in albumin and easily digestible ; ice and refresh- 
ing and cooling drinks should be given freeh\ In addi- 
tion, decinormal saline solution should be injected. In 
sapremia the first thing to be done is to remove the focus 
of decomposition, the dead fetus or fetal remains, but 
without producing any new lesions. Before and after the 
operation the uterus should be irrigated with 3 per cent. 



294 PATHOLOGY OF THE PUERPERIUM. 

carbolic-acid or 1 per cent, lysol solutions, or the uterine 
wall cauterized with concentrated carbolic acid. After 
the operation is completed, iodoform or itrol pencils (silver 
citrate) should be introduced into the cavity, or the entire 
uterus packed with iodoform or itrol gauze. 

(7) Metrophlebothrombosis. — In phlebothrombosis the 
thrombi which normally close the vessels of the placental 
site extend into the veins of the entire uterine wall and 
even as far as the internal ovarian veins, from which 
emboli are thrown off and make their way into the general 
circulation and into all the organs, especially into the 
lungs. If the thrombi undergo decomposition or become 
infected by pathogenic micro-organisms, the emboli them- 
selves carry the infection and set up metastatic abscesses 
wherever they go — in the spleen, which is usually enlarged, 
in the kidneys, in the liver, producing intense jaundice, 
and especially in the lungs, joints, eyes, and skin. The 
condition is not so frequent as metrolymphangitis. The 
peritoneum and pleura are not rarely affected. 

Symptoms and Diagnosis, — After mild symptoms of 
endometritis, or even quite unexpectedly, with or with- 
out pain or hemorrhage, a violent chill makes its appear- 
ance with marked rise in the temperature and followed by 
profuse sweating. There is great tenderness over the 
uterus, while the pain in the abdomen is slight and 
present only in circumscribed areas. 

These attacks of metastatic pyemia occur repeatedly, 
so that the patient rapidly goes into a state of collapse 
with violent headache and marked precordial oppression. 
Gradually the symptoms of the individual metastatic 
affections make their appearance. Death usually occurs 
after two or three weeks of violent remittent and inter- 
mittent fever, as has been described. Phlegmasia alba, 
dolens, which is not very dangerous as a primary condi- 
tion, often occurs secondarily by thrombosis of the femoral 
veins, and manifests itself as a tense whitish swelling of 
the skin covering the thighs. 

Treatment. — In the prophylaxis, which is of the highest 



TREATMENT OF SEPTICEMIA AND SAPREMIA. 295 

importance, several sources of danger must be carefully 
kept in view : 

(1) The formation of large thrombi is to be avoided by 
removing any possible cause of uterine hemorrhage. 

Among such causes we have : 

(1) Insufficient contraction — either a mere irregularity in the 
contractions of the uterine muscle without marked hemorrhages, 
or paralyses localized at the placental site with severe and dan- 
gerous metrorrhagia. 

(2) The retention of fetal remains. These usually lead to 
hemorrhage only in the first week, but they may, by undergoing 
decomposition, lead to putrefaction of the thrombi and secondary 
hemorrhages. 

(3) Atony of the uterine muscle, especially at the placental site, 
due to subinvolution ; this usually leads to slight but repeated 
hemorrhages after the first week. 

(4) Endometritis, which is often the primary cause of the 
atony, may also lead to putrefaction of the thrombi and inflamma- 
tory hyperemia. 

(e5) Venous stasis ; this may also produce hemorrhage if neigh- 
boring organs are engorged, if the woman is allowed to get up too 
soon, or if the abdominal muscles are unduly exerted, as in 
straining at stool, cough, and various kinds of work, if the circu- 
lation is impeded by angulation or displacement of the uterus. 

Emotional excitement and sudden attacks of fever re-enforce 
these predisposing factors by the acute Ijyperemia which they 
occasion. 

(2) The decomposition of the thrombi is to be avoided 
by immediate local treatment of the puerperal endome- 
tritis. 

(3) If putrefaction has occurred, measures must be 
adopted to check its progress and prevent the expulsion 
of emboli by bringing about contraction of the uterus, dis- 
infecting the lochia, and by insisting on absolute rest in bed 
in the dorsal position, forbidding any kind of movement, 
such as sitting up for the purpose of emptying the bowels, 
etc., and combating constipation, ischuria, and bronchial 
catarrh. 

(4) If, in spite of these precautions, emboli are formed, 
the organism must be brought into a condition to neu- 
tralize the ptomains by feeding the patient on light, 



296 PATHOLOGY OF THE PUERPERIUM. 

Fig. 159. Puerperal Diphtheritic Endometritis and Colpitis.— The 
thrombi at the placental site have undergone suppuration. Case of 
eclampsia (original water-color). 

digestible diet (every two hours) and by supporting the 
strength with cooling drinks and alcoholic stimulants, as 
explained in a preceding paragraph {q. v.). Alcohol is 
indicated, especially in cardiac weakness, which should 
also be combated by injections of ether and camphor, warm 
baths or warm packs after Priessnitz or Jacquet; for 
diaphoresis, cold sponging and douching. 

To counteract the evil effects of decomposition of the 
thrombus, mercury, and possibly also the silver salts in 
the form of ointments have been found useful (see Treat- 
ment of Metrolymphangitis). 

I 27. INTERDEPENDENCE BETWEEN THE PUERPERAL 
PROCESSES AND OTHER DISEASES. 

In the paragraphs on Pregnancy and Labor the alarming influ- 
ence of certain diseases on the puerperium was mentioned (see 
II 14 and 33). The febrile infectious diseases, especially erysipe- 
las, croupous pneumonia, and influenza must be regarded as 
serious complications of a puerperium, not only because of their 
effect on the general condition but also on account of the dis- 
turbances in the pulmonary circulation to which they, give rise. 
The existence of a pseudoscarlatinoid form of sepsis has been 
alluded to in 1 14. Influenza may act as the cause of the endo- or 
parametritis; the author is in a position to confirm the occur- 
rence of excessively painful labor-pains and afterpains; anom- 
alies in the lochial discharges which are reduced in quantity, of 
a purulent consistency and brownish color, and do not become 
fetid until the third or fourth day ; rise in temperature, 102.2° to 
104° F. (39° to 40° C), without any marked acceleration of the 
pulse (108 to 120) ; and a tendency to marked diaphoresis, vomit- 
ing, meteorism, and diarrhea without peritonitis. Occasionally 
influenza becomes complicated with a streptococcal infection of 
the endometrium and the disease assumes a grave septic character. 

Treatment. — Diaphoresis ; laxatives ; enemata, and rectal and 
vaginal irrigations ; Priessnitz compresses on the abdomen and 
breast ; sali^yrin ; very light diet, frequently administered in 
small quantities. 

Cardiac disease without compensation and pulmonary disease 
not rarely lead to pulmonary edema and later to progressive 



72. 




Fig. 159. 



%.^ 



V 



■/,;,„/,; \!i}viri>P!> 



PUERPERAL PROCESSES AND OTHER DISEASES. 297 

miliary tuberculosis. The proper treatment should be instituted 
during the puerperium (see H 14 and 23). 

Among nervous diseases we have already mentioned the occur- 
rence during the puerperium of psychoses, which may or may not 
have been present before, especially melancholia with secondary 
anemia and the effects of chorea and myelitis. The prognosis of 
a psychosis depends on whether it is hereditary or not. 

Diseases affecting the metabolism, and urinary diseases, includ- 
ing secondary amaurosis, are, as a rule, favorably influenced by 
the puerperium. Eclampsia rarely occurs in the puerperium and, 
if it does, runs a milder course; but this is not the case if the 
attacks continue after the expulsion of the child. Coma is occa- 
sionally followed by protracted loss of memory, by psychoses, and 
by amaurosis. 

Tumors of the genital tract may become daDgerons in 
various ways. A myoma will usually undergo involu- 
tion ; but, if the nutrition is disturbed, it may degenerate 
or decompose and produce most unfavorable conditions. 
Ovarian Gysts, on the other hand, continue to grow and, 
as the pedicle is apt to be twisted or crushed, necrosis or 
decomposition is very likely to result. 

Treatment. — Hemorrhages due to myomata are to be 
treated during and after labor as explained in § 23, 
No. 1, and later on in the puerperium with ergot or 
ergotin. Pedunculated polypi extending into the cervix 
or even into the vagina must be removed immediately 
after delivery on account of the danger of gangrene. 
Other tumors which are not readily accessible should be 
let alone. . If they undergo decomposition they must be 
removed, and if this cannot be effected through the 
vagina, a celiotomy is to be performed, followed by total 
extirpation of the infected uterus. 

If ovarian cysts are not complicated by torsion of the 
pedicle or suppuration or sloughing, nothing should be 
done until the end of the puerperium, but if such com- 
plications exist ovariotomy should be performed at once. 

There is a wide field for the exercise of prophylaxis in 
the treatment of relaxed conditions of the abdominal and 
pelvic organs due to loss of elasticity and tonus in the 
striated and unstriated muscles, including, therefore, the 



298 



PATHOLOGY OF THE PUEEPERIUM. 



walls of the vessels. The immediate consequences of this 
condition are postpartum hemorrhages from the flaccid 
uterus, which is usually much depressed and in a condi- 
tion of retroversion. During the puerperium the hemor- 
rhage manifests itself by the presence of blood in the 
lochial discharges, which retain their hemorrhagic char- 
acter and become profuse. This appears to indicate a 
retention of the secretions in the relaxed uterus, a condi- 
tion which I have already referred to under the name of 




Fig. 19.— Abdominal scar after an operation for the removal of an 
ovarian cyst in the fourth month of prejjnancy. Note the peculiar 
distribution of the pigment, corresponding with the sutures and the 
scar (from a case of the author's on the fourth day after a spontaneous 
delivery). 

lochiometra. The entire abdomen becomes distended 
with gas, the normal functions of the intestine and of the 
bladder are practically abolished often as long as one or two 
weeks after delivery, and the abdominal muscles become 
completely relaxed. Passive congestion in the entire ab- 
dominal distribution of the splanchnic nerve affects the 



MAM3IARY GLANDS DURING THE PUERPERIUM. 299 

mammary glands to such an extent that milk secretion 
soon ceases or may even fail to become established. 

The ultimate result of neglecting these conditions is 
permanent agalactia, distention of the abdomen— often 
associated with dysmenorrhea or lasting amenorrhea— 
backward displacement and descent of the uterus with 
congestion or inflammation and gastro-enteroptosis. 

Treatment.— kh(\om\\r^i\ massage, a tight binder to the 
abdomen, ergotin, the introduction of a pessary about 
the end of the first week, with proper attention to the 
regulation of the bowels (after the second day) and of the 
bladder. 

1 28. DISEASES OF THE MAMMARY GLANDS DURING 
THE PUERPERIUM. 

Inflammation of the mammary gland, or mastitis, is a 
tedious and more or less serious, but rarely a fatal disease. 
It is due to the action of staphylococci and streptococci 
which make their entrance through minute solutions of 
continuity in the skin, usually fissures about the nipple ; 
thecocci^are also found in the ducts of the gland, but 
their virulence appears to be much attenuated. Either 
they establish themselves about smaller ducts and i« the 
acini and set up inflammation and suppuration in them 
(parenchymatous mastitis), or they follow the course ot 
the interlobular connective tissue (interstitial mastitis) or, 
finally, a retromammary abscess may form. ^ 

Symptoms.— ^ome difficulty is experienced m finding 
the fissures, which are usually hidden in the minute fur- 
rows between the glands of Montgomery. Sometimes 
they are very painful and are then found to be ulcerated 
and covered with an exudate. 

From these excoriations a cord-like wheal extends to 
the nearest lobule, in which the inflammatory process 
manifests itself early by a tense hardness and increased 
sensitiveness to pressure. The surrounding skin becomes 
reddened ; later edema develops and indicates the forma- 



300 PATHOLOGY OF THE PUERPERWM. 

tion of a deep al)scess. This is soon followed either by 
fluctuation or by the formation of minute fistulse, beneath 
which there is an extensive suppuration. Owing to the 
plentiful supply of lymphatics in the organ the fever is 
very high — 104° F. (40° C.) and over is nothing unusual. 
The occurrence of suppuration is usually preceded by a 
chill. 

The individuals most predisposed are, of course, those 
of weak and scrofulous constitution, and the suppuration 
in these cases may, in spite of energetic treatment, gradu- 
ally extend from lobule to lobule and may even involve 
the other breast. In some cases, which are fortunately 
extremely rare, general sepsis develops. 

During the winter of 1898 to 1899 I observed a case of this kind 
for seven weeks. The mother was young and in very delicate health. 
There were old scars from the removal of lymphatic glands in the 
neck. The woman was in miserable circumstances and had been 
attacked by influenza shortly before her confinement. In spite of 
ice-bags, compresses, and early incisions, the entire glandular 
tissue of both breasts was gradually destroyed. The skin was 
undermined in both directions by small fistulae, while several deep 
abscesses, varying in size from a walnut to an apple, had formed 
in the substance of the gland. It was evident that the tissues of 
the glands had lost all their bactericidal power. 

Treatment. — The fissures about the nipple should be 
covered with cloths wrung out in aluminium acetate and 
the breasts emptied with a glass breast-pump, which may 
also be used as a precautionary measure in the other breast. 
The plan of hardening the nipples during pregnancy does 
not recommend itself to the author (see § 10), at least, 
not with brandy ; daily washing with cold water or 30 
per cent, tincture of nut2:all may, however, be tried 
(Ahlfeld). 

If inflammation has already developed in the surround- 
ing tissue, the affected breast should be allowed to rest for 
a few days and dressed with compresses wrung out in 
lead acetate. The same treatment is employed if one of 
the lobes is distinctly hard. Compresses are wa'ung out 
in lead-water cooled with ice and changed every five to 



MAMMARY GLANDS DURING THE PUERPERIUM. 301 

fifteen minutes. At the first sign of suppuration, such as 
edema of the skin, that is to say, very early, the breast is 
incised and drained, counter-drainage being established if 
necessary, and the wound irrigated through and through. 
Light, nutritious diet should be ordered, the bowels regu- 
lated, and measures adopted to promote diaphoresis. 

Hypersecretion of the mammary glands manifests itself 
in polygalactia, i. e., simple hypersecretion, and in galac- 
torrhea, a condition in which the milk flows in an unin- 
terrupted stream ; it is evidently due to disturbance of 
the innervation. The symptoms at first are the same as 
those which attend prolonged lactation, dragging pains in 
the breast and back, feeling of oppression in the stomach, 
loss of appetite, visual disturbance, chlorosis, weakness. 
Before long, however, the symptoms of oligemia become 
more marked. The patient complains of palpitation of 
the heart, the pulse is small and rapid, oliguria, convul- 
sions, and attacks of syncope make their appearance. The 
treatment consists in massage, compression by means of a 
bandage, iodine and sodium iodide internally. 



302 



PATHOLOGY OF THE PUERPEBIUM. 



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EXPLANATORY NOTE. 

Each illustration is provided with a description found 
at the top of the even page, above the main text. The 
reference letters and numbers in the descriptions are espe- 
cially chosen for each illustration ; but in addition to these, 
another set of numbers has been used in the description 
of the many sagittal sections and other illustrations of the 
pelvis, identical with the numbers used in the Atlas of 
Labor and Operative Obstetrics. They are the following : 



1, Symphysis. 


27. 


Anterior superior spines. 


2. Promontory. 


28. 


Ala of sacrum. 


2a. Double promontory. 


29. 


Sacro-iliac articulation. 


3. Coccyx. 


30. 


Ileopubic tubercle. 


4. Cervix. 


31. 


Acetabulum. 


4a. External os. 


32. 


Ueosacral ligaments ; poste- 


46. Internal os. 


rior 


superior spines. 


5. Bladder. 


33. 


Femur. 


6. Vagina. 


34. 


Anterior inferior spines. 


7. Kectum. 


35. 


Obturator foramen. 


7a. Anus. 


37. 


Ovary. 


8. Walls or body of uterus. 


38. 


Oviduct (tube). 


9. Spines of the ischium. 


39. 


Broad ligament. 


10. Tuberosities of the ischium. 


40. 


1 Anterior and posterior 
] sacro-iliac ligaments. 


14. Perineum. 


41. 


16. Umbilical cord. 


42. 


Eound lieament. 


17. Placenta. 


43. 


Ovarian ligament. 


20. Eima pudendi. 


44. 


Sagittal suture, 


21. Lower uterine segment. 


45. 


Lesser fontanel. 


26. Tumor. 







306 



INDEX. 



Abdomen, conical, Pig. 127 

pendulous, Figs. 99, 128, 129 
Abdominal pregnancy, 195 ; Fig. 

116 
Abortion, 31 

anomalies that lead to, IS-i 

at end of second month, Fig. 8 

criminal, 167 

diagnosis, 134 

from endometritis, 14-4 

from subchorionic hemorrhage, 
138, 141 

from syphilis, 149 

treatment, 134 

with hydatid moles, 146 
Acantho}Delys. 242 ; Fig. 148 
After-birth, expulsion of, 97 
After-pains, excessive, 277 
Alexins, bactericidal, 101 
Allantoic sac, 22 
Amnion, 21 
Amniotic fluid. 21 

sac. 28 
Ampulla of uterus, 20 
Anatomical features of pregnancy 

in each month, 30 
Anemia of pregnancy. 163 
Anomalies in labor-pains, 268, 270 

of fetal membranes, dTstocia 
from, 266 

of genitals, effect on pre2;nancv, 
168 

of umbilical cord, dystocia from, 
266 
Anteflexion of gravid uterus, 174 
Anteroposterior diameter of pelvic 

outlet, 51 
Anteversio flexio uteri, 175 
Arbor vitae uteri, 25 



Arteries of uterus. 26 ; Fig. 31 
Artificial feeding, 118 
Assimilation-pelves, 241 
Atony of uterine muscle, 272 
Atresia of cervix, dystocia from, 
258 
of hymen, dystocia from, 258 
of vagina, dystocia from, 258 
Auscultation in diagnosis of preg- 
nancy. 37 

Bacteria of vagina, 103 
Bacterial infection in labor, 101 
Basedow's disease and pregnancy, 

163 
Baudelocque, diameter of, 51 
Biedert's cream-mixture. 122 
Blastodermic vesicle. 21 
Blastula, 21 

Bones of infant, development, 110 
Brain of fetus, morphology, 109 
Bruit, uterine. 32 

Caxal of Xuck, 79 
Cancer of uterus, 189 
Carcinoma, dystocia from, 262 
Cardiac insufficiency and labor. 

274 
Cattle, importance of. 120 
Cellulitis, pelvic, 286 
Cephalic presentation in flat pel- 

yis, Fig. 129 
Cervical canal, examination of. 43 
Cervix, lacerations of, 252 

uteri, 25 
Cholera and pregnancy. 156. 164 
Chorion. 23 

epithelioma of, 146 
Chorionic villus, Fig. 16 

' 307 



308 



INDEX. 



Circulation in new-born infant, 

Circumference of pelvis, 51 
Classification of deformed pelves, 

212 
Collapsed pelves, 222 
Colostrum, 108 
Colostrum-cells, Fig. 85 
Colostrum-corpuscles,*107 
Colpeurynter, 172 
Colpitis, puerperal, 285 
Conception, failure of, 179 
Conduplicatio corpore, Fig. 57 
Conical abdomen, Fig. 127 
Conjugate, diagonal, 53 
diameter, 55 
true, 53 
Contracted pelvis, Figs. 50, 120 

anteroposteriorly, 215 

generally, 212 

obliquely, 230 

transversely, 236 
Contraction-ring, 77 
Convulsive labor-pains, 271 
Corpus luteum, 19 ; PL 1, Fig. 2 
Crede's method of expressing pla- 
centa, 98 
Criminal abortion, 167 
Cystic enchondroma, Fig. 150 
Cystocele, dystocia from, 259 

Decidua cells, 27 ; Fig. 15 
necrotic, 104 
polyposa, 145 
reflex a, 23 
vera, 23 ; Fig. 10 
Decidual endometritis. Fig. 90 
hemorrhages, abortion from, 
138 
Decubital pelvis, 228 ; Fig. 5 
Deformed pelves, 209 ; Pis. 25, 56, 

57 
Deformities of pelvis, pregnancv 

and, 204 
Dembo's ganglion, 73 
Dermoid cysts and pregnancy, 

188 
Development of ovum, 15 
Deventer's pelvis, 215 
Diabetes, pregnancy and, 163 



Diagnosis of pregnancy, 11. See 
also Pregnancij^ diagnosis of. 
Diagonal conjugate, 63 
Diameter of Baudelocque, 51 
Diameters of pelvic inlet. Fig. 70 

of pelvis, 50 
Diet in pregnancy, 124 

in puerperium, 125 
Differential diagnosis of preg- 
nancy, 47 
Digestive organs of new-born in- 
fant, 111 
Dilatation stage of labor, 75 
Diphtheritic ulcers, puerperal, 284 
Discus proligerus, 17 
Disinfecting parts for vaginal ex- 
amination, 39 
Displacements of uterus, 170 
Ductus Arantii, 29 
Botalli, 29 

omphalomesaraicus, 21 
Duncan's method of expelling pla- 
centa, 98 
Dwarf pelvis, 212 
Dvstocia from anomalies of fetus, 
262 
of umbilical cord and fetal 
membranes, 266 
from hydrocephalus, 264 
from malformation of genitals, 

254 
from twin pregnancy, 262 

Eclampsia gravidarum, 152 

treatment, 155 
Ectoderm, 21 
Ectopic gestation, 191 

treatment, 197 
Eighth month, signs of pregnancv 

in, 34 
Embryo, development of, 21 
Endometritis, Fig. 90 
abortion from, 144 
decidualis cystica. 145 
puerperal, 285 
Entoderm, 21 

Epilepsy and pregnancy, 164 
Epithelioma of chorion, 146 
Erosions of uterine wall in labor, 
251 



INDEX. 



309 



Erysipelas and prejjnancy. 156 
Examination, internal, in diagno- 
sis of pregnancy, 38 

of pelvis, 48 
Expulsion, muscles of, 91 

of placenta, 97 

stage of labor. 85 
External oblique diameter. 51 

OS, 25 

False pelvis, 5-4 
Feeding, artificial, 118 

of new-born infant, 108 
Fertilization, 19 

Fetal membranes, anomalies of, 
dystocia from, 266 
development, 21 
pelvis. 228 
Fetus, anomalies of. dvstocia from. 
'262 
malformations of. dvstocia from. 

264 
nutrition and oxygenation of. 28 
papyraceus, 137, 263 
Fibrin, subamniotic, 149 ; PI. 41 
Fibroma of uterus, dvstocia from. 

260 
Fibromyoma, Fig. 106 
and pregnancy, 177 
Fifth month, signs of prescnancv 

in, 32 
First month, signs of pre^nancv 
in, 30 
stage of labor, 75 
Fixation, point? of. 77, 79, 80 
Flat non-racbitic pelvis. 215 ; 
Fig. 118 
pelvis, cephalic presentation in. 

Fig. 130 

rachitic pelvis, 217 ; Fig. 119 

Flexion of uterus, dystocia from, 256 

Fourth month, gravid uterus in, 

Fig. 19 

signs of pregnancy in. 32 

Fulminating puerperal peritonitis, 

291 
Funic soutRe. 37 
Funnel-shaped pelvis. 225 : Figs. 

51, 134 
Fiirther's Kinderzwieback. 119 



Galactorrhea. 301 
Gangrenous peritonitis, 291 
Gartner's feltmilch. 119 
Generally contracted pelvis. 212 
Genital secretions, care of. 102 
Genitalia, lacerations of. in labor. 

243 
Genitals, malformations <»f. dys- 
tocia from. 254 
Gestation, ectopic, 191 

treatment, 197 
Gravid uterus in fourth month. 
Fig. 19 
in second month. Fig. 18 
in sixth month. Fig. 20 
in third month. Fig. 17 
\ Gunshot wounds and pregnancv, 
I 166 

Haptogexic membrane. 107 
Head, distortions of. during labor. 

89 
Hegar-s sign. 31. 43 
Hemophilia and pregnancy, 163 
Hernia labialis uteri gravidi bicor- 
nis, 172 
of gravid uterus. 177 
: Heubner-Soxhlet method for arti- 
ficial feedincr. 120 
Hydatid mole. 140^; Fig. 89 
Hydrocephalus, PI. 61, a 
brow presentation, PI. 61 
; dvstocia from. 264 
I Hydrorrhachis, 242 
' Hydrorrho?a uteri gravidi. 144 
Hygiene of pregnancy, 123 
Hymen, atresic, dystocia from, 258 
Hyperemesis, 161 
' gravidarum, 231 
I Hysteria and pregnancy. 164 
; Hysterocele, 177 

: Icterus gravidarum. 163 

' Impetigo herpetiformis gravida- 
rum, 157 

i Impres^nation, 20 

! Infant, bodily temperature of. 114 
circulation in. 111 
digestive organs of. 111 
feeding of. 108 



310 



INDEX. 



Infant, histological changes in, 109 

new-born, care of, 122 

nutrition of, 108 

physiology, 108 

weight of, 112, 113 
Infantile pelvis, 225 ; Fig. 134 
Infectious diseases and pregnancy, 

156 
Inflammation of placenta, 149 
Influenza and pregnancy, 156 

influence of, on labor, 275 
Infundibulopelvic band, 15 
Injuries to child from deformed 

pelvis, 207 
Inspection in diagnosis of preg- 
nancy, 36 
Instrumental labor, 278 
Instruraentarium, 281 
Intercristal diameter, 50 
Interspinal diameter, 50 
Intertrochanteric distance, 51 
Intoxications and labor, 278 

pregnancy and, 160 
Intra-abdominal pressure, 68 
Intra-uterine pressure, 68 
Inversion of uterus, 274 
Involution of uterus, 98 
Ischuria in labor, 277 

paradoxical, 171 

JusTOMAjOR pelves, 243 
Juvenile pelvis, 212 

Kidney disease and pregnancy, 
164 

of pregnancy, 164 
Kyphoscoliotic pelvis, 229 
Kyphotic pelvis. Fig. 136 

Labok and diseases of other or- 
gans, 274 
deformities of pelvis and, 204 
dilatation stage, 75 
erosions of uterine wall in, 251 
examination in, 278 
expulsion stage, 85 
first stage, 75 
instrumental, 278 
instruments for, 280 
laceration of cervix in, 252 



Labor, missed, 73 

normal, 62 

onset of, 72 

pathology, 243 

preparations for, 278 

rupture of uterus in, 243 

second stage of, 85 

uterine muscles during, 62 
Labor-pains, 67 

abnormally vigorous, 271 

anomalies in, 268, 270 

convulsive, 271 

diminution in force of, 271 

increase of force of, 270 
Lacerations of cervix, 252 

of genitalia durinp- labor, 243 
Lactation, care of mother in, 132 
Lactiferous sinus, 107 
Ligamentum cardinale, 78 
Liquor amnii, 30 

folliculi, 17 
Lithopedia, 138 
Lochia, 97, 104 

alba, 104 ; Fig. 84 

and milk-secretion, 105 

rubra, 104 ; Fig. 82 

serosa, 104 ; Ffg. 83 
Lower uterine segment, 77, 81 
Lumbosacrokyphotic pelvis, 228 
Lung diseases and pregnancy, 159 
Lvmphatics of female genitalia. 
Fig. 78 

MALroRMATiONS of fetus, dys- 
tocia from, 264 
of genitals, dystocia from, 254 
of uterus, 168 
Malignant deciduoma, 146 
Mammary gland, diseases of, dur- 
ing puerperium, 299 
hypersecretion of, 301 
inflammation of, 299 
of blonde. Fig. 80 
secreting cells of. Fig. 79 
Masculine pelvis, 212 
Mastitis, 299 

Maturity of child, signs of, 35 
Mayer's ring-pessary, 172, 174 
Medullary canal, 21 
folds, 21 



INDEX. 



311 



Meningocele, dystocia from, 265 
Menstruation, 17 

after childbirth, 133 
Mesoderm, 21 
Metabolism, disturbances of, and 

pregnancy, 160 
Metritis, puerperal, 286 
Metrolymphangitis, septic, 289 

treatment, 292 
Metrophlebothrombosis, 294 
Milk, Fig. 86 

composition of, 107 
Milk-secretion, 106, 132 

lochia and, 105 
Missed labor. 78 
Mole, hydatid, 145 ; Fig. 89 
Monsters, dystocia with, 265 
Morsus diaboli, 20 
Mucous membrane of uterus, re- 
generation of, 105 
Miiller's ring, 76 
Multiple pregnancy, 262 
Mummified fetus, Fig. 88 
Muscles engaged in expulsion, 91 
Myelitis and labor, 278 
Myoma and pregnancy, 178 

and puerperiura, 297 

effects of pregnancy on, 180 

uterine. Fig. 108 
treatment, 184 
Myomectomv and pregnancv, 183, 

185 
Myxoma chorii multiplex, 145 

Nagele's obliquity, 85. 216 

pelvis, 233 
iSTecrotic decidua, Fig. 81 

of a hematoma mole, Fig. 88 
I^fepbritis and pregnancy, 164 

influence of, on labor, 275 
Nephrorrhapliy during preg- 
nancy, 167 
Nerve-supply of female genitalia, 

74 
Nervous diseases and pregnancv, 

160 
Nestle 's food, 119 
Neuralgia and labor, 277 
Neuritis and labor, 278 
and pregnancy, 164 



Neuroses, influence of, on labor. 
275 

New-born infant, treatment, 96 
Ninth month, signs of pregnancv 

in, 34 
Normal labor, 62 
Nuck, canal of, 79 
Nutrition of fetus, 28 

Obliquely contracted pelves, 

230; Figs. 139-142 
Obliquity, Nagele's, 85, 216 

Solayre's, 85 
Omphalocele, dystocia from, 265 
Operations during pregnancv, 

165 
Ossification in normal epiphysis. 
Fig. 124 
in rachitic epiphysis. Fig. 125 
Osteomalacic bone, section 
through. Fig. 126 
collapsed pelvis, 223 
pelvis, Fig. 123 
Ostium abdominale, 20 
Ovarian arteries. 26 

cysts and puerperium, 297 
pregnancy, 197 ; Fig. 115 
tumors, pregnancy and, 186 
dystocia from, 261 
treatment, 188 
Ovary, 15; PI. 1, Fig. 1 

longitudinal section of, PI, 1, 
Fig. 3 
Oviduct, cross-section of. 16 
Ovulation, 17 
Ovum, development, 15 
in second month. Fig. 12 
in third month. Fig. 13 
Oxygenation of fetus, 28 

Palpation in diagnosis of preg- 
nancy, 37 

Paracolpitis, 286 

Paradoxical ischuria, 171 

Paragomphosis, 214 

Parametritis, 101 
puerperal. 286 

Parturient canal, anatomical char- 
acters of, 75 

Pathology of labor, 243 



312 



INDEX. 



Pathology of pregnancy, 134 

of puerperium, 283 
Pelveoperitonitis, 289 

treatment, 292 
Pelves, assimilation, 241 

collapsed, 222 

deformed, 209 ; Pis. 25, 56, 57 
classification of, 212 

justomajor, 243 

obliquely contracted, 230 

rubber, 224 

transversely contracted, 236 
Pelvic cellulitis, 287 

expansion, plane of, 85; Fig. 72 

inlet, diameters of. Fig. 70 
Pelvimetry, 50, 205 
Pelvis, anatomy of, 49 

anomalies of shape of, and preg- 
nancy, 167 

anteroposteriorly contracted, 215 

bone-tumors of, 242 

changes in development, 58 

circumference of, 51 

contracted, Fis:. 50 

decubital, 228 T Fig. 51 

deformities of, influence of, on 
labor, 204 

diameters of, 50 

dwarf, 212 

examination of, 48, 49 

external measurements of, 50 

false, 54 

fetal, 58, 228 ; Figs. 52, 53 

flat non-rachitic, 215, 217 ; Fig. 
118 
rachitic, 217 ; Fig. 119 

funnel-shaped, 225; Figs. 50, 
134 

generallv contracted, 212 ; Fig. 
120^^ 

halisteretica, 223 

inclination of, 56 
variations in, 60 

infantile, 225; Fig. 134 

juvenile, 212 

kyphoscoliotic, 229 

kyphotic, Fig. 136 

lumbosacrolcyphotic, 228 

masculine, 212 

Nagele's, 233 



Pelvis nana, 212 
normal, Fig. 49 
obliquely contracted, 230 ; Figs. 

139-142 
osteomalacic, Fig. 123 

collapsed, 223 
pseudo-osteomalacic, 220 ; Fig. 

122 
Pvobert's, 236 ; Fig. 144 
rubber, 224 
shape of, 56 
sitz, 237 
spiny. Fig. 148 
split. Fig" 147 
spondylolisthetic, 239 ; Fig. 

143 
synostotic, 233 
true, 54 
Pendulous abdomen. Figs. 99, 128. 

129 
Perforation peritonitis, 167 
Perimetritis, 101 
Perineum, muscles of, 74 
Peritonitis, fulminating puerperal, 
291 
gangrenous, 291 
perforation, 167 
puerperal, 289 
Pfliiger's cell-cords, 16 
Phlegmasia alba dolens, 294 
Phthisis, influence of, on preg- 
nancy, 159 
Physiologv of new-born infant, 
108 
of pregnancy, 11 
of puerperium, 96 
Placenta circumvallata, 28 
expulsion of, 97 
inflammation of, 149 
prjevia, 199 ; Fig. 23 
course, 202 
diagnosis, 202 
marginal. Fig. 27 
treatment, 203 
premature separation of, 267 
retention of, 267 
scroti na, 28 

succenturiata, 199; Fig. 13 
syphilis of, 149 
velamentous insertion of, 201 



INDEX. 



313 



Placental infarct, Figs. 95, 101 

in eclampsia, Fig. 96 
Plane of greatest pelvic expansion, 
54 

of inlet, 54 

of least pelvic expansion, 55 
of outlet, 55 

of pelvic expansion, 85 ; Fig. 72 
Plicae palmate^, 25 
Pneumonia and pregnancy, 159 
Polygalactia, 301 
Polyhydramnion, 147 
Portio vaginalis, examination of, 

41 
Position. Walcher, 60 
Pregnancv, abdominal, 195 ; Fig. 
116 
alterations of non-sexual organs 

in, 46 
anatomical features of, 30 
and diseases of other organs, 

156 
anomalies of genitals and, 168 
deformities of pelvis and, 204 
diagnosis, 11 

auscultation in, 37 
examination, 35 
in eicchth month, 34 
in fifth month. 32 
in first month, 30 
in fourth month. 32 
in ninth month, 34 
in second month, 31 
in seventh month, 33 
in sixth month, 33 
in tenth month, 34 
in third month, 31 
inspection in, 36 
internal examination in, 38 
diagnostic signs of, 45 
differential diagnosis of, 47 
ectopic, 191 

treatment, 197 
hygiene of, 123 
management of, 123 
ovarian, 197 ; Fig. 115 
pathology, 134 
physiology, 11 

reasons for determining exist- 
ence of, 11 



Pregnancy, signs of, 12 
termination of, 44 
traumatism during, 165 
tubal, 191 ; Fig. 112 
tubo-ovarian, 197 
tumors and, 177 
twin, 262 

uterine displacements and, 170 
Prescriptions used in obstetric 

practice, 302 
Principal plane of Yeit, 89 ; Fig. 

71 
Procho\vnik"6 diet, 116 
Prolapse of gravid uterus, 173 

of umbilical cord, 266 
Pseudo-osteomalacic pelvis, 220 ; 

Fig. 122 
Ptyalism and pregnancy, 162 
Puerpera, treatment of, 130 
Puerperal colpitis, 285 

diphtheritic endometritis, Fig. 
159 
ulcers of vulva and vagina, 
284 
endometritis, 285 
fever. 101, 131, 283 
metritis, 286 
parametritis, 286 
peritonitis, 289 

fulminating, 291 
processes and other diseases, 296 
salpingitis, 289 
uterus, Fig. 28 
section of, Fig. 87 
Puerperium, 96 
management, 125 
pathology, 283 
physiology, 96 
symptomatology. 125 
tumors and, 297 
Pulse in puerperium. 105 
I Purpura hemorrhagica and preg- 
nancy, 163 
Pyelonephritis and pregnancy, 

164 
Pyofibrinous peritonitis, 291 

Eegeneration of uterine mucous 

membrane, 105 
Kenal diseases and pregnancy, 164 



314 



INDEX. 



Restitution-force of uterus, 68 
Retention of placenta, 267 
Retractores uteri, 79 
Retroflexion of gravid uterus, 170; 

Fig. 102 
Retroversion of gravid uterus, 170 
Robert's pelvis, 236 

transversely contracted pelvis, 
Fig. 144 
Rotation, first, 85 
second, 85 
third, 95 
varieties of, 96 
Rubber pelvis, 224 
Ruge's muscle-rhomboids, 64 
Rupture of cervix and vaginal 
fornix, 92 
of tubal sac, 167 
of uterus, 167 

complete, ' Fig. 1 52 
in labor, 243' 
transverse. Fig. 110 
Ruptured tubal gestation-sac, Fig. 
113 

SACCULATioisr of uterus, dystocia 

from, 256 
Sacrum, curve of, in normal, 

rachitic, and osteomalacic 

pelves. Fig. 131 
Salpingitis, puerperal, 289 

treatment, 292 
Sapremia, 291 

treatment, 293 
Sarcoma deciduocellulare, 146 
Scarlatina and pregnancy, 157 
Schultze's method of separating 

placenta, 97 
Scorbutus and pregnancy, 163 
Second month, gravid uterus in. 

Fig. 18 
signs of pregnancy in, 31 
stage of labor, 85 
Septic metrolymphangitis, 289 
Septicemia, treatment, 293 
Septicopyemia, 291 
Seventh month, signs of preg- 
nancy in, 33 
Sight, appearance of, in infant, 

160 



Signs of pregnancy, 12 

relative value of, 13 
Sitz pelvis, 237 
Sixth month, fetus of, 34 

gravid uterus in, Fig. 20 
signs of pregnancy in, 33 
Skull, configuration of, 85 
fetal, size of, 86 
of child at term, Figs. 73, 74 
of infant at term, dimensions of, 
87 
Solayre's obliquity, 85 
Soldner's condensed cream, 122 
Souffle, funic, 37 
Soxhlet's method of feeding, 118 
Spasms, influence of, on labor, 276 
Spina bifida, dystocia from, 265 
Split pelvis. Fig. 147 
Spondylolisthetic pelvis, 239 ; 

Fig. 143 
Stratum vasculosum, 64 
Subamniotic fibrin, 149 ; PL 41 
Subchorionic hemorrhage, PI. 41 
Syncytium, 27 
Synostotic pelvis, 233 
Syphilis of placenta, 149 . 
Syphilitic umbilical cord, section 
of, Fig. 94 

Temperature in new-born in- 
fant, 114 
Tenth month, signs of pregnancy 

in, 34 
Tetanus and pregnancy, 156 

uteri, 270 
Tetany and pregnancy, 164 
Third^ month, gravid uterus in, 
Fig. 17 
signs of pregnancy in, 31 
Torsion of umbilical cord, 266 
Transverse diameter, 55 
of outlet, 54 
of pelvic outlet, 51 
Transversely contracted pelves, 

236 
Traumatism during pregnancy, 

165 
True pelvis, 64 
Tubal menstruation, 19 
pregnane}^, 191 ; Fig. 112 



INDEX. 



315 



Tubal sac, rupture of, 167 
Tuberculosis and labor, 274 
Tubo-ovarian pregnancy, 197 
Tumors, 177 

and the puerperium, 297 

of pelvic bones, 242 

of vagina, dystocia from, 259 

ovarian, dystocia from, 201 
Tunica albuginea ovarii, 16 
Tussis uterina, 163 
Twin pregnancy, 262 
Typhoid fever and pregnancy, 156 

Umbilical arteries, 29 

cord, anomalies of, dystocia 
from, 266 

prolapse of, 266 

torsion of, 266 

twisting of, rig. 100 
Uterine bruit, 32, 37 

contractions, causes of, 73 
fibromata, dystocia from, 260 
isthmus, 20 
muscle, atony of, 272 

during pregnancy and labor, 
62 
segment, lower, 77, 81 
wall, erosions of, in labor, 251 
Uterus, anatomv of, 25 
arteries of, 26 ; Fig. 31 
bicornis, 168 

septus, Fig. 97 
bilocularis, 168 
cancer of, 189 
didelphys, 168 
displacements of, 170 
flexion of, dystocia from, 256 
gravid, anteflexion of, 174 

hernia of, 177 

prolapse of, 173 

retroflexion of, Fig. 102 

retroversion of, 170 
introrsum arcuatus, Fig. 98 
inversion of, 274 



Uterus, involution of, 98 
malformations of, 168 
of fetus, section of, Fig. 14 
pregnant, venous plexuses of, 

Fig. 77 _ 
puerperal, Fig. 28 
rupture of, 167 

complete, Fig. 152 

in labor, 243 

transverse. Fig. 110 
sacculation of, dvstocia from, 

257 
septus, 168 

dystocia from, 255 
unicornis, 168 

dystocia from, 254 

pregnancy in, Fig. Ill 

VACCTNATioisr and pregnancy, 156 
Vagina, bacteria of, 103 
puerperal diphtheritic ulcers of, 

284 
septa, dystocia from, 258 
Vaginal examination in diagnosis 
of pregnancy, 38 
tumors, dystocia from, 259 
Variola and pregnancy, 156 
Yeit, principal plane of, 84, 89 
Velamentous insertion of placenta. 

201 
Venous plexuses of pregnant 

uterus, Fig. 78 
Vomiting of pregnancy, 31 
Yulva of primigravida, Fig. 37 
puerperal diphtheritic ulcers of, 
284 

Walchee position, 60 

Weight of infant, variations in, 

113 
Wetnurses, qualifications of, 121 

Zona granulosa, 17 
pellucida, 17, 21 



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DAVIS'S OBSTETRIC NURSING. 

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DESCHWEINITZ ON DISEASES OF THE EYE. Third Edition, 
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DORLAND'S DICTIONARIES. 

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THE INTERNATIONAL TEXT=BOOK OF SURGERY. In Two 
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JACKSON'S DISEASES OF THE EYE. 

A Manual of Diseases of the Eye. By EDWARD JACKSON, A. M., M. D., 
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KEATING'S LIFE INSURANCE. 

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KEEN ON THE SURGERY OF TYPHOID FEVER. 

The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. 
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KEEN'S OPERATION BLANK. Second Edition, Revised Form. 

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KYLE ON THE NOSE AND THROAT. Second Edition. 

Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical 
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LAINE'S TEMPERATURE CHART. 

Temperature Chart. Prepared by D. T. Laine, M. D. Size 8x135^ 
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LEVY, KLEMPERER, AND ESHNER'S CLINICAL BACTERI= 
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The Elements of Clinical Bacteriology. By Dr. Erxst Levy, Professor 
in the University of Strasburg, and Dr. Felix Klemperer, Privatdocent 
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LOCKWOOD'S PRACTICE OF MEDICINE. 

.\ Manual of the Practice of Medicine. By GEORGE RoE LOCKWOOD, 
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LONG'S SYLLABUS OF GYNECOLOGY. 

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MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W, ]\LacDOXALD, :\L D. Edin., 
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MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 

Pathological Technique. A Practical Manual for Laboratory Work in 
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McFARLAND'S PATHOGENIC BACTERIA. Third Edition, 
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Text-Book upon the Pathogenic Bacteria. By Joseph McFarland, 
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MEIGS ON FEEDING IN INFANCY. 

Feeding in Early Infancy. By Arthur V. Meigs, M. D. Bound in limp 
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MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M. D., Professor 
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MORTEN'S NURSES' DICTIONARY. 

Nurses' Dictionary of Medical Terms and Nursing Treatment. Containing 
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ATLAS AND EPITOME OF SKIN DISEASES. 

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ATLAS AND EPITOME OF SPECIAL PATHOLOGICAL HIS= 
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By Dr. H. Durck, of Munich. Edited by LUDWlG Hektoen, M. D., 
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ATLAS AND EPITOME OF LABOR AND OPERATIVE OB- 
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ATLAS AND EPITOME OF OBSTETRICAL DIAGNOSIS AND 
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17 



CLASSIFIED LIST 

OF THE 

MEDICAL PUBLICATIONS 

OF 

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ANATOMY, EMBRYOLOGY, HIS- 
TOLOGY. 

Bohm, Davidoff, and Huber— A Text- 
Book of Histology, 4 

Clarkson— A Text-Book of Histology, . 5 

Haynes— A Manual of Anatomy, ... 7 

Heisler — A Text-Book of Embryology, . 7 

Leroy — Essentials of Histology, .... 15 

Nancrede — Essentials of Anatomy, ... 15 
Nancrede — Essentials of Anatomy and 

Manual of Practical Dissection, .... 10 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology, .... 15 

Crookshank — Bacteriology, 5 

Frothingham — Laboratory Guide, ... 6 
Levy and Klemperer's Clinical Bacte- 
riology, 9 

Mallory and Wright— Pathological 

Technique, 9 

McFarland — Pathogenic Bacteria, ... 9 

CHARTS, DIET-LISTS, ETC. 

Griffith— Infant's Weight Chart, .... 7 

Hart — Diet in Sickness and in Health, . 7 

Keen — Operation Blank, 8 

Laine — Temperature Chart, 9 

Meigs — Feeding in Early Infancy, ... 10 

Starr — Diets for Infants and Children, . 12 

Thomas — Diet-Lists, 13 

CHEMISTRY AND PHYSICS. 

Brock\A/ay — Essentials of Medical 

Physics, 15 

Wolff— Essentials of Medical Chemistry, 15 

CHILDREN. 
An American Text-Book of Diseases 

of Children i 

Griffith— Care of the Baby 7 

Griffith— Infant's Weight Chart, .... 7 
Meigs — Feeding in Early Infancy, ... 10 
Powell — Essentials of Diseases of Chil- 
dren, 15 

Starr — Diets for Infants and Children, . 12 

DIAGNOSIS. 

Cohen and Eshner — Essentials of Diag- 
nosis, 15 

Corwin — Physical Diagnosis, 5 

Macdonald — Surgical Diagnosis and 

Treatment, 9 

Vierordt— Medical Diagnosis, 14 

DICTIONARIES. 

The American Illustrated Medical 

Dictionary, • • 3 

The American Pocket Medical Dic- 
tionary, 3 

Morton— Nurses' Dictionary, 10 



EYE, EAR, NOSE, AND THROAT. 

An American Text-Book of Diseases 
of the Eye, Ear, Nose, and Throat, . . i 

De Schweinitz — Diseases of the Eye, . 6 

Friedrich and Curtis — Rhinology, Lar- 
yngology, and Otology, 6 

Gleasjn — Essentials of Diseases of the 
Ear, 15 

Grunwald and Grayson — Atlas of Dis- 
eases of the Laryn.x, 16 

Haab and De Schweinitz — Atlas of Ex- 
ternal Diseases of the Eye, 16 

Jackson — Manual of Diseases of the Eye, 8 

Jackson and Gleason — Essentials of 
Diseases of the Eye, Nose, and Throat, 15 

Kyle — Diseases of the Nose and Throat, 9 

GENITO-URINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 2 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 8 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . . 15 

Mracek and Bangs — Atlas of Syphilis 
and the Venereal Diseases, 16 

Saundby — Renal and Urinary Diseases, 11 

Senn— Genito-Urinary Tuberculosis, . . 12 

Vecki — Sexual Impotence, 14 

GYNECOLOGY. 

American Text-Book of Gynecology, . 2 

Cragin — Essentials of Gynecology, ... 15 

Garrigues — Diseases of Women, . ... 6 

Long — Syllabus of Gynecology, .... 9 

Penrose — Diseases of Women, 10 

Pryor — Pelvic Inflammations, 11 

Schaeffer and Norris — Atlas of Gyne- 
cology, 17 

MATERIA MEDICA, PHARMA- 
COLOGY, AND THERAPEUTICS. 

An American Text-Book of Applied 

Therapeutics i 

Butler— Text-Book of Materia Medica, 

Therapeutics, and Pharmacology, . . 4 
Cerna — Notes on the Newer Remedies, . 4 
Morris — Essentials of Materia Medica 

and Therapeutics, 15 

Saunders' Pocket Medical Formulary, . 11 
Sayre — Essentials of Pharmacy, .... 15 
Stevens — Manual of Therapeutics, ... 13 
Stoney— Materia Medica for Nurses, . . 13 
Thornton— Dose-Book and Manual of 

Prescription- Writing, 13 

MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

Chapman— Medical Jurispi-udence and 
Toxicology, 5 



MEDR -A L P UBLICA TIONS 



19 



Golebiewski and Bailey— Atlas of Dis- 
eases Caused by Accidents, 17 

Hofmann and Peterson — Atlas of Legal 
Medicine, 16 

NERVOUS AND MENTAL DIS- 
EASES, ETC. 

Chapin— Compendium of Insanity. ... 5 
Church and Peterson — Nervous and 

Mental Diseases, 5 

Shaw — Essentials of Nervous Diseases 

and Insanity, 15 

NURSING. 
Davis — Obstetric and Gynecologic Nurs- 
ing, 6 

Griffith— The Care of the Baby, .... 7 

Hart — Diet in Sickness and in Health, . . 7 

Meigs — Feeding in Early Infancy, ... 10 

Morten — Nurses' Dictionary, 10 

Stoney — Materia Medica for Nurses, . . 13 

Stoney — Practical Points in Nursing, . . 13 

Stoney — Surgical Technic for Nurses, . 13 

Watson — Handbook for Nurses, .... 14 



OBSTETRICS. 

An American Text-Rook of Obstetrics 
Ashton — Essentials of Obstetrics, . . . 
Boisliniere — Obstetric Accidents, . . 
Borland — Manual of Obstetrics, . . . 
Hirst — Te.\t-Book of Obstetrics, . . . 
Norris — Syllabus of Obstetrics, . . . . 
SchaefFer and Edgar— Atlas of Obstet- 
rical Diagnosis and Treatment, . . . . 



17 



PATHOLOGY. 

An American Text-Book of Pathology, 2 
Durck and Hekto = n — Atlas of Patho- 
logic Histologj-, 16 

Kalteyer — Essentials of Pathology, . . 15 
Mallory and Wright — Pathological 

Technique, g 

Senn — Pathology', and Surgical Treat- 
ment of Tumors, 12 

Stengel— Text-Book of Pathology, ... 12 
W^arren— Surgical Pathology, 14 

PHYSIOLOGY. 

An American Text-Book of Physiol- 
ogy', 2 

— Essentials of Physiology', 15 

Raymond— Manual of Physiology, . . 11 
Stewart— Manual of Physiology, ... 13 

PRACTICE OF MEDICINE. 

An American Year-Book of Medicine 
and Surgery-, 3 

Anders— Text-Book of the Practice of 
Medicine, 4 

Eichhorst — Practice of Medicine. ... 6 

Lockwood — Practice of Medicine. ... 9 

Morris— Essentials of Practice of Medi- 
cine, 15 

Salinger and Kalteyer— Modern Medi- 
cine, II 

Stevens— Manual of Practice of Medi- 
cine, 12 



SKIN AND VENEREAL. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 3 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 8 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . . 15 

Mracek and Stelwagon — Atlas of Dis- 
eases of the Skin, 16 

Stelwagon— Essentials of Diseases of 
the Skin, 15 

SURGERY. 

An American Text-Book of Surgery, 2 
An American Year-Book of Medicine 

and Surgery, 3 

Beck — Fractures, 4 

Beck — Manual of Surgical Asepsis, ... 4 

Da Costa — Manual of Surgerj', 5 

International Text-Book of Surgery, . 8 

Keen— Operation Blank, 8 

Keen — The Surgical Complications and 

Sequels of Typhoid Fever, 8 

Macdonald — Surgical Diagnosis and 

I'reatment, 9 

Martin — Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . . 15 

Martin — Essentials of Surgery, 15 

Moore — Orthopedic Surgerj', 10 

Nancrede — Principles of Surgerj', . . . 10 

Pye — Bandaging and Surgical Dressing, 11 

Scudder — Treatment of Fractures, ... 12 

Senn — Genito-Urinary Tuberculosis, . . 12 

Senn— Practical Surgerj-, 12 

Senn — Sjilabus of Surgery, 12 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 12 

Warren — Surgical Pathology and Ther- 
apeutics, 14 

Zuckerkandl and Da Costa — Atlas of 

Operative Surgery, 16 

URINE AND URINARY DISEASES. 

Ogden — Clinical E.xamination of the 

Urine, 10 

Saundby — Renal and Urinary Diseases, 11 
Wolff — Examination of Urine, 15 

MISCELLANEOUS. 

Abbott — Hygiene of Transmissible Dis- 
eases, 3 

Bastin — Laboratory Exercises in Bot- 
any. . . 4 

Golebiewski and Bailey — Atlas of Dis- 
eases Caused by Accidents, . . • • 17 
Gould and Pyle — Anomalies and Curi- 
osities of Medicine, 7 

Grafstrom — Massage, 7 

Keating— Examination for Life Insur- 
ance, 8 

Pyle — A Manual of Personal Hj-giene, . n 
Saunders' Medical Hand-Atlases, . 16,17 
Saunders' Pocket ^ledical Formulary, . n 
Saunders' Question-Compends, . . 14, 15 
Stewart and Lawrence — Essentials of 

Medical Electricity, 15 

Thornton — Dose-Book and Manual of 

Prescription- Writing, 13 

Van Valzah and Nisbet — Diseases of 
the Stomach, 13 



Nothnagel's Encyclopedia 

OF 

Special Pathology and Therapeutics. 



¥T is universally acknowledged that the Germans lead the world in Internal Medicine; 
* and of all the German works on this subject. Nothnagel's " Special Pathology and 
Therapeutics" is conceded by scholars to be without question the best System of 
Medicine in existence. So necessary is this book in the study of Internal Medicine 
that it comes largely to this country in the original German. In view of these facts. 
Messrs. W. B. Saunders & Company have arranged with the publishers to issue at once 
an authorized edition of this great encj'clopedia of medicine in English. 

For the present a set of some ten or twelve volumes, representing the most practical 
part of this encyclopedia, and selected by a competent editor with especial thought of the 
needs of the practical physician, will be published. Thesevolumes will contain the 
real essence of the entire work, and the purchaser will therefore obtain at less than half the 
cost the cream of the original. Later the special and more strictlj' scientific volumes will 
be offered from time to time. 

The work will be translated by men possessing thorough knowledge of both English and 
German, and each volume will be edited by a prominent specialist on the subject to 
which it is devoted. It will thus be brought thoroughly up to date, and the American edition 
will be more than a mere translation of the German ; for, in addition to the matter contained 
in the original, it will represent the very latest views of the leading American special- 
ists in the various departments of Internal ]\Iedicine. The whole System will be under the 
editorial supervision of a cli^ncian of recognized authority, who will select the subjects 
for the American edition, and will choose the editors of the different volumes. 

Unlike most encyclopedias, the publication of this work will not be extended over a 
number of years, but five or six volumes will be issued during the coming year, and the 
remainder of the series at the same rate. Moreover, each volume will be revised to the 
date of its publication by the American editor. This will obviate the objection that has 
heretofore existed to systems published in a number of volumes, since the subscriber will 
receive the completed work while the earlier volumes are still fresh. 

The usual method of publishers, when issuing a work of this kind, has been to compel 
physicians to take the entire Sj'stem. This seems to us in many cases to be undesirable. 
Therefore, in purchasing this encyclopedia, physicians will be given the opportunity of 
subscribing for the entire System at one time; but any single volume or any number of 
volumes may be obtained by those who do not desire the complete series. This latter 
method, while not so profitable to the publisher, offers to the purchaser many advan- 
tages which will be appreciated by those who do not care to subscribe for the entire work 
at one time. 

This American edition of Nothnagel's Encyclopedia will, without question, form the 
greatest System of Medicine ever produced, and the publishers feel confident that it 
will meet with general favor in the medical profession. 

20 



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